Smoking Pot Related to Higher Lung Disease Risk in HIV-Positive Men

Researchers compared lung disease diagnoses among groups of HIV-positive and HIV-negative men who reported marijuana use.

This article points to some interesting research and was written by Benjamin Ryan from Poz.com   


Among men who have sex with men (MSM) living with HIV, smoking marijuana is associated with a higher risk of both infectious and noninfectious lung diseases.

Publishing their findings in EClinicalMedicine, researchers studied 1996 to 2014 data on men from the Multicenter AIDS Cohort Study (MACS), a long-term observational cohort of HIV-positive and HIV-negative MSM. Participants eligible for this particular prospective cohort study were 30 years old or older and had provided self-reported data on marijuana and tobacco smoking during biannual study visits.

The study included 1,352 HIV-positive men who were matched with the same number of HIV-negative men according to race and the age at which they entered the study. Between them, the cohort members made 53,794 study visits and were followed for a median of 10.5 years.

Twenty-seven percent of the HIV-positive men and 18 percent of the HIV-negative men reported smoking marijuana daily or weekly during one or more years of follow-up, for use that lasted for a median of 4.0 and 4.5 years, respectively.

The cohort members received 1,630 diagnoses of lung diseases during follow-up. A total of 33.2 percent of the HIV-positive men and 21.5 percent of the HIV-negative men were diagnosed with infectious lung disease, and a respective 20.6 percent and 17.2 percent were diagnosed with noninfectious lung disease.

Among the men living with HIV, recent marijuana smoking was associated with a 43 percent higher risk of infectious lung disease and a 54 percent higher risk of noninfectious lung disease independent of tobacco smoking and other risk factors for lung disease. When HIV-positive men smoked both marijuana and tobacco, these risks were higher.

There was no association between recent marijuana smoking and lung disease risk among the HIV-negative men.

The study’s strength included its large sample size, the high number of lung diagnoses and the lenghty follow-up time.

“These findings could be used to reduce modifiable risks of lung disease in high-risk populations,” the study authors concluded.

To read the study, click here.

Even When Well Treated, HIV Is Linked to Advanced Aging

Researchers analyzed 10 biomarkers associated with biological aging among a group of HIV-positive and -negative Europeans.

This article is a reprint from POZ.com  from January 17, 2019  By Benjamin Ryan

Publishing their findings in the journal AIDS, researchers from the ComorBidity in Relation to AIDS (COBRA) study analyzed 134 people with HIV and 79 HIV-negative people with similar sociodemographic and lifestyle factors. The participants were recruited in Amsterdam (these were at least 45 years old) and London (these were at least 50 years old).

All the HIV-positive individuals were on antiretrovirals and had had a fully suppressed viral load for at least 12 months.

The researchers also studied samples from 35 blood donors selected from the Dutch national blood bank in Amsterdam. They were matched with the HIV-positive and -negative individuals from the COBRA study according to age and had all tested negative for HIV, hepatitis B and C viruses (HBV/HCV), syphilis and human T-lymphotropic virus 1 and 2 (HTLV).

The investigators tested the participants for 10 biomarkers that previous research has indicated are associated with biological, as opposed to chronological, aging.

Among the COBRA study members, biological age was greater than chronological age by an average of 13.2 years among those with HIV and 5.5 years among those without the virus. For the blood donors, biological age was an average of 7.0 years lower than chronological age.

After adjusting the data for various factors, including HIV status, the study authors found that the following factors were significantly associated with a greater average biological age compared with chronological age: chronic HBV, 10.05 years; total anti-cytomegalovirus (CMV) IgG antibody levels, 1.83 years per 10-fold increase; and CD8 cell count, 0.44 years per 100-cell increase.

After adjusting for chronic HBV infection status, total anti-CMV IgG antibody levels and CD8 levels, the analysis indicated that the HIV-positive COBRA participants had a greater discrepancy between biological and chronological age compared with their HIV-negative counterparts (4.5 years on average) and with the blood donors (19.0 years on average).

After conducting another analysis in which they adjusted the data for various factors, the study authors found that HIV-related factors associated with a greater biological age compared with chronological age included: cumulative exposure to the antiretroviral Invirase (saquinavir), 1.17 years per year of exposure; a lowest-ever (nadir) CD4 count of less than 300, 3.0 years; chronic HBV, 7.35 years; and total anti-CMV IgG antibody level, 1.86 years per 10-fold increase.

My Health Record

AFAO have just released a Consumer fact Sheet about My health record, telling you about what it is and how it can be of use to you.

You can find it here – My Health Record Fact Sheet

Beyond Positive Workshop Series

Beyond Positive is a workshop series for HIV Positive Gay and Homosexually Active Men.

Topics include Sex, Intimacy and Relationships, Stigma & Discrimination, Disclosure & Empowerment, Treatments as Prevention, Living Well and more.

Facilitated by Mark Reid, the Positive Peer Educator. The workshops will run weekly on a Tuesday evening from 6:30pm from November 14th to December 12th.

  • Tuesday November 14th
  • Tuesday November 21st
  • Tuesday November 28th
  • Tuesday December 5th
  • Tuesday December 12th

Evaluation and Debrief on Tuesday December 12th followed by dinner at 7.30pm. If have any special dietary requirements please let Mark know when you RSVP.

If you’re interested in this event, please contact:
Mark Reid on 9482 0000 or email mreid@waaids.com by Tuesday October 31st 2017 to secure a place.

Not linked in with the WA AIDS Council? Not to worry. If you haven’t connected with the WA AIDS Council previously and would like to register for this event, please contact Alli at apaterson@waaids.com or on 9482 0000, who will explain how you can get involved.

International HIV Conference Reveals Exciting Progress in Global HIV Fight

Highlights from the research presented at the 9th International AIDS Society Conference on HIV Science in Paris. Thanks to the team at Poz.com for this great coverage that I think makes interesting reading.

August 22, 2017  By Benjamin Ryan

The fight to combat the global HIV epidemic is charting exciting progress on numerous fronts. This includes a rapidly increasing proportion of those living with the virus on treatment as well as falling infection and AIDS-related death rates. Additionally, there have been various promising advances in research into new antiretroviral (ARV) treatments and forms of pre-exposure prophylaxis (PrEP), not to mention vaccines and means of prompting long-term viral remission that may allow some people with the virus to stop taking daily drugs.

The more than 7,000 HIV researchers and advocates who attended the 9th International AIDS Society Conference on HIV Science (IAS 2017), which took place in Paris from July 23 to 26, learned of these and other signs of great hope for the future of the worldwide epidemic. However, they were also confronted with the finer details of the considerable challenges ahead, most notably flat or declining funding from wealthy donor nations for efforts to fight the epidemic in poorer nations.

To follow is a summary of the major findings presented at the conference. Click on the hyperlinks for greater detail about any of the studies. For a complete newsfeed of all IAS 2017 reporting, click here.

Linda-Gail Bekker, PhD, the International AIDS Society (IAS) President and International Scientific Chair of IAS 2017 in Paris, speaking at the opening sessionBenjamin Ryan

Global Treatment

major announcement from Joint United Nations Programme on HIV/AIDS (UNAIDS) kicked off the conference: An estimated half of all people living with HIV worldwide,19.5 million out of 36.7 million, are now on ARV treatment. According to a lengthy UNAIDS report on the state of the global epidemic, in 2016 an estimated 70 percent of the global HIV population had been diagnosed, 77 percent of those diagnosed were on ARVs and 82 percent of those on ARVs had a fully suppressed viral load. Since 2014, UNAIDS has pushed nations to get each of those three figures to 90 percent, otherwise known as the 90-90-90 targets.

Treatment rates have soared while new infections and AIDS-related deaths have dropped considerably in eastern and southern Africa in particular. Meanwhile, Central Asia and Eastern Europe is the only major region that has seen a worsening epidemic, with its HIV infection rate rising 60 percent and its AIDS-related death rate rising 27 percent during the 2010s.

UNAIDS

UNAIDS

Excitingly, a highly reliable survey conducted in Swaziland and presented at IAS 2017 found that in just five years the hard-hit nation had doubled the proportion of its HIV population on ARVs while cutting its new infection rate in half.

Velephi Okello of the Swaziland Ministry of Health at IAS 2017 in ParisBenjamin Ryan

Globally, people with HIV are starting ARV treatment progressively earlier. However, the median CD4 count at treatment initiation remains above 350, indicating that considerable work needs to be done to move closer to treating everyone living with the virus, as recommended by the World Health Organization (WHO).

The continued flat funding seen in recent years for the effort to fight HIV in lower-income nations threatens progress in treating HIV on a grand scale. One analysis presented at the conference projected that if funding continues only at current levels, the proportion of people with the virus on treatment and virally suppressed will stagnate accordingly.

Jessica McGillen, PhD, presents a key slide that projects the impact of U.S. funding on viral suppression rates in 18 sub-Saharan African nations.Courtesy of Benjamin Ryan

Another threat to progress fighting global HIV is WHO’s finding that HIV drug resistance is on the rise. In numerous nations recently surveyed, 10 percent of those starting HIV treatment had a strain of virus resistant to some of the most widely used ARVs.

HIV Treatment as Prevention

Yet another study has seen no transmissions within a large cohort of partners when the HIV-positive member of a mixed-HIV-status couple is on ARVs and has an undetectable viral load. Between the Opposites Attract study reported at the Paris conference and the previously reported PARTNER study, there are now data on about 35,000 condomless sex acts between such gay male partners without a single HIV transmission. The PARTNER and HPTN 052 studies have also seen no transmissions between heterosexual partners within such a context. The PARTNER study is currently in a new phase to gather more data from gay male couples.

According to scientific experts discussing these collected research findings at the Paris conference, the risk of transmitting HIV through condomless sex when an individual has an undetectable viral load is so vanishingly small that it is effectively zero.

Another study presented at the conference raised worries about how poor adherence to ARVs among youths may compromise the powerful effects of HIV treatment as prevention. An analysis of 13- to 24-year-olds receiving ARV treatment in Philadelphia found that about one in six were episodically at high risk of transmitting the virus.

PhiladelphiaIstock

Viral Remission

Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases (NIAID), says he no longer talks about an effort to develop an HIV cure, per se. Instead, he prefers the goal of prompting “viral remission” or “post-treatment control” of the virus, in which an individual maintains an undetectable viral load without daily ARV treatment. Conference attendees learned that a 9-year-old South African child has been in such a state for eight years, following just 40 weeks of ARV treatment begun after the child contracted the virus at birth.

Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases (NIAID), speaking at IAS 2017Benjamin Ryan

An additional presented case study described how a man who contracted HIV only days before starting Truvada (tenofovir disoproxil fumarate/emtricitabine) as PrEP and who was quickly put on a full HIV treatment regimen spent seven months off treatment before experiencing a viral rebound.

HIV Prevention, Including Vaccines

A major push in the HIV research field is to find effective so-called broadly neutralizing antibodies against the virus for use in vaccines, as PrEP or as treatment. Addressing concerns about how to mass-produce such antibodies, one team of researchers found that they could prompt their production by immunizing calves.

In an early-stage study, one HIV vaccine candidate showed promise by prompting a robust immune response in a small collection of volunteers. Pending the results of another study, this vaccine may go into an advanced global trial as soon as late 2017.

Following definitive studies showing that voluntary medical male circumcision reduces female-to-male HIV transmission by about 60 percent, there has been a massive effort to circumcise men in sub-Saharan Africa in recent years. Research over the past few years has begun to show that this endeavor has likely driven down infection rates among men. Now, a study presented at IAS 2017 indicated that women also likely benefit from the male circumcision push, with lower rates of associated HIV and herpes simplex virus type 2.

Cancer

major forum exploring how much HIV and cancer treatment researchers have to learn from and share with one another as they develop highly advanced forms of treatment preceded the conference. The two fields share the goal of overcoming the immune system’s inability to combat a malignant force, be it a tumor or HIV-infected immune cells.

HIV Drug Development

The long-acting injectable regimen of cabotegravir and Edurant (rilpivirine) given every four or eight weeks successfully suppressed HIV over a 96-week period among 90 percent of participants in a major trial.

Gilead Sciences recently applied for approval from the U.S. Food and Drug Administration (FDA) of its new combination tablet of the experimental integrase inhibitor bictegravir plus the contents of the company’s Descovy (emtricitabine/tenofovir alafenamide). The FDA granted the tablet priority review; a decision is expected by February 12, 2018. A study presented at IAS 2017 found that compared with other approved regimens, this combination had fewer side effects and was similarly effective in suppressing HIV among those starting ARVs for the first time.

Another study found that the first single-tablet regimen containing a protease inhibitor, specifically Prezista (darunavir), was highly effective in suppressing HIV. When combined with Tybost (cobicistat) and Descovy (emtricitabine/tenofovir alafenamide), Prezista led to a continued undetectable viral load among 96 percent of those who switched from a successful multi-tablet ARV regimen.

Additionally, a recent study found that among first-timers to HIV treatment, a new single-tablet combo regimen containing the investigational non-nucleoside reverse transcriptase inhibitor doravirine, Epivir (lamivudine) and Viread (tenofovir disoproxil fumarate) causes fewer central nervous system and metabolic side effects and is as effective as Atripla (efavirenz/tenofovir disoproxil fumarate/emtricitabine).

PrEP

Researchers are fast at work exploring new forms of PrEP to help address issues such as toxicity, adherence and the need for novel, female-specific forms of HIV prevention.

One study validated ongoing advanced research into a long-acting injectable form of PrEP, finding that long-acting cabotegravir given every eight weeks was well tolerated and yielded drug levels expected to afford maximum protection against HIV. Additionally, a study of a vaginal ring form of PrEP given to teenage girls in the United States found that an ARV-containing monthly ring was safe and that the participants used it well.

Various studies addressed the ongoing question of how starting PrEP affects sexual risk taking and rates of sexually transmitted infections (STI) among men who have sex with men (MSM). An analysisof British MSM on Truvada for HIV prevention found that they tended to fold PrEP into their set of personal HIV risk-reduction rules, sometimes easing those rules when taking PrEP. Self-reporting indicated that the men did not tend to simply abandon condoms wholesale. Meanwhile, a long-term study of MSM in the United States found that those who started PrEP tended to proceed to report higher rates of condomless sex with casual partners, in particular with HIV-positive partners.

At London’s 56 Dean Street, the city’s main sexual health clinic catering to MSM, gonorrhea diagnoses fell 24 percent between 2015 and 2016 while HIV rates dropped 42 percent. This occurred as use of PrEP soared among men using the clinic’s services and as the clinic, instigated impressive new policies to encourage HIV and STI testing and to treat individuals for both types of infections as soon after diagnosis as possible.

The 56 Dean Street clinic in LondonBenjamin Ryan

PrEP use in the United States continues to increase, reaching the current estimate of 136,000 users. However, the rate of increase in those starting PrEP seen in each progressive quarter has slowed (in other words, about the same number of people are beginning PrEP each quarter). Troublingly, PrEP use is apparently still largely relegated to white MSM age 25 and older, raising concerns that those at the very highest risk for the virus, young Black MSM in particular, will for the most part fail to benefit from the highly effective HIV prevention method that has now been on the market for five years.

new analysis found that the non-daily dosing protocol for PrEP, known as on-demand PrEP, studied in the French and Canadian IPERGAY trial of high-risk MSM worked well even when the men had sex infrequently. There have been concerns that the high level of protection seen among men in the study, who were instructed to take Truvada only in the couple of days surrounding sex, was likely a by-product of the fact that the men tended to have sex so frequently that they often wound up maintaining a relatively steady level of Truvada in their bloodstream—rather than the result of the particulars of the dosing protocol.

separate study of Dutch MSM examined the reasons why they preferred on-demand versus daily PrEP, as well as their reasons for switching between the protocols or stopping them altogether. An expectation of better adhering to one protocol over another was found to be a major deciding factor. Additionally, a national survey of U.S. MSM found that concerns about the cost of PrEP and associated side effects are major barriers to men using Truvada for prevention.

Scientists Shed Light on How HIV Raises Heart Disease Risk

Researchers found a way to block a protein linked with blood clotting and inflammatory processes using a drug derived from tick saliva.

August 30, 2017 – reprinted from Poz.com

Researchers have uncovered a new pathway by which HIV leads to the chronic inflammation and immune activation associated with an increased risk of cardiovascular disease. Using an experimental drug based on an anticlotting factor in tick saliva, the scientists were able to block this pathway in primates. Such success indicates that a drug may one day be developed that helps mitigate the increased risk of heart disease associated with HIV.

Even when taking a successful antiretroviral (ARV) regimen, people with HIV have up to a two-fold increased risk of cardiovascular disease, including heart attack and stroke, compared with HIV-negative individuals. Researchers believe that the chronic inflammatory state and the persistent activation of the immune system to which the virus gives rise is likely a major driver of this increased risk.

major clinical trial called REPRIEVE is currently investigating whether a drug from the cholesterol-lowering class called statins may mitigate this risk and provide other health benefits among people with HIV who would not otherwise qualify for a statin.

Publishing their findings in Science Translational Medicine, National Institute of Allergy and Infectious Diseases (NIAID) scientists studied blood samples from people with HIV. They discovered elevated levels of immune cells known as monocytes that expressed high levels of a protein known as a tissue factor, which is linked with blood clotting and processes that give rise to inflammation.

The scientists further discovered that the level of such monocytes remained high regardless of whether the HIV-positive people who provided the blood samples had a fully suppressed virus thanks to ARV treatment.

Next, the researchers exposed the blood samples to an experimental drug called lxolaris, which is based on an anticlotting factor found in tick saliva. Previous research has shown that lxolaris blocks the cellular pathway that activates the tissue factor protein. The investigators found that the drug indeed shut off that particular protein in monocytes and did not otherwise affect normal cell function.

Studying monkeys infected with SIV, HIV’s simian cousin, the investigators found that the animals also had high levels of tissue-factor-expressing monocyte cells. So they treated five monkeys with lxolaris and found that this lowered levels of biomarkers that predict abnormal blood clotting and immune activation.

This finding signifies that by targeting the tissue factor pathway, lxolaris may lower some risk factors for cardiovascular disease among people with HIV. The drug has not yet been tested in humans, however, so considerable research would be needed to determine whether lxolaris may slow the inflammation and clotting processes that raise the risk of cardiovascular disease among people with HIV.

Worried About HIV and Aging? The First Thing to Do Is Stop Smoking

 

At a time when we consider the impacts of aging and HIV together this article from Roger Pebody that was recently published on The Body is worth a read.

It highlights that impact that smoking has on us as we live longer with HIV and some of the implications that has on us.

January 11, 2017

The DMV Balenciaga House Meeting
Credit: sayhmog for iStock via Thinkstock

People living with HIV often worry about whether HIV is accelerating the aging process. HIV itself isn’t making many people ill, but some people with HIV are having problems with heart disease, cancers and brittle bones. These conditions — typically experienced as people get older — seem to be occurring at higher rates in people with HIV than in the general population. And they seem to be occurring at a younger age.

In trying to understand why this may be, you can find yourself delving quite deeply into some pretty technical and occasionally obscure areas of HIV science. It seems that people living with HIV may lose some degree of immune function over time, compounding deficits that typically occur in later years. Further, chronic inflammation — in other words, the immune system being in a constant state of high-alert in response to HIV infection — appears to have harmful effects on cells, tissues and processes.

For the moment, the practical implications of this emerging field of knowledge are unclear. Specific therapies to counteract chronic inflammation do not exist.

But the studies on age-related conditions and life expectancy do give some clear indications of what people living with HIV can do to improve their health as they get older.

Smoking and Life Expectancy

Let’s take, for example, a recent study that looked at death rates among clients of Kaiser Permanente. It compared almost 25,000 HIV-positive people with ten times that number of HIV-negative people.

There have been steady increases in life expectancy for people with HIV since 1996, but a troubling gap remains between their life expectancies and those of HIV- negative clients. Based on 2011 estimates, a 20-year old living with HIV could be expected to live to the age of 69, compared with an HIV-negative person living to the age of 82 — a thirteen-year difference.

But the researchers identified some people with HIV who had better prospects: People who began HIV treatment with a CD4 account above 500 could be expected to live to 74. And people who began treatment at that stage and had never smoked would live to 79.

Further exploring the impact of smoking on life expectancy, another group of researchers recently put data on the health of Americans living with HIV into a mathematical model. The researchers took as their example people who are diagnosed with HIV and start antiretroviral therapy (ART) at the age of 40.

They found that — on average — a male smoker with HIV who carried on using cigarettes would live until the age of 65. This compared with 72 years for a man who had never smoked.

A female smoker with HIV would live to 68, compared with 74 for a female non-smoker.

When looking at how a male smoker living with HIV could improve his prospects, the researchers found that quitting smoking would have the greatest impact, by adding almost six years of extra life.

Smoking and Disease

Smoking cuts people’s lives short through strokes, heart attacks and other forms of cardiovascular disease; cancers of the lung, mouth, esophagus and bladder; emphysema, bronchitis and other forms of chronic obstructive pulmonary disease — to list just a few.

Smoking could both shorten your life and have a significant impact on your quality of life. None of those health conditions are especially pleasant to live with.

That’s true for everyone, HIV positive and HIV negative. But it looks as if smoking — in some cases — may do more damage to HIV-positive than HIV-negative people. It may have a greater physiological impact on HIV-positive people.

For example, a very thorough Danish study compared the risk of heart attack in people living with HIV and people in the general population. Matching people of the same age and gender, it found that current smokers living with HIV had an almost three-fold increased risk of heart attack compared with smokers who were HIV negative. Ex-smokers living with HIV had an almost two-fold increased risk.

But people living with HIV who had never smoked had no greater risk of heart attack than matched non-smokers in the general population.

Similarly, smoking seems to have more of an impact on chronic obstructive pulmonary disease in people living with HIV than in other people.

Focus on What Can Be Changed

Rates of smoking are alarmingly high in people living with HIV. Researchers recently pooled the results of 45 different studies from North America and Europe. They found that 54% of people with HIV were smokers. That’s in contrast with just 15% of the general population of the United States.

There are people out there who are anxious about the impact HIV has on the aging process, but who continue to smoke. This is to be preoccupied by a threat that we don’t quite understand and are not sure how to deal with, while neglecting a very real health threat that can be changed and brought under control.

Physicians and community organizations need to make helping people give up smoking central to the way they take care of the health of those living with HIV. Achieving change in this area may make more difference than almost anything else they do.

And people living with HIV need to be ready to seek and accept help with getting over this addiction. It’s important to know that nicotine replacement products (such as patches and sprays) and the medications bupropion and varenicline are proven to help people quit smoking. Combining this with counseling or other support can further boost the chances of staying off tobacco in the long term.

A Centers for Disease Control and Prevention campaign features “tips from former smokers“. One former smoker is Brian, a man living with HIV who survived a stroke. He contrasts smoking with HIV, which he says will be part of his life forever: “Smoking is something that you do have control over,” he says. “You can stop. And it’s worth your life to stop smoking.”

Copyright © 2017 Remedy Health Media, LLC. All rights reserved.

 

BREASTFEEDING WITH AN UNDETECTABLE VIRAL LOAD: WHAT DO WE KNOW?

This article from Megan DePutter in the UK asks a range of questions that constantly get asked around undetectable viral load and breastfeeding.  As she says it is so important that every woman gets all the facts and then makes her own choices.

MEGAN DEPUTTER ON WHY UNDETECTABLE DOES NOT EQUAL UNTRANSMITTABLE IN THE CASE OF BREASTFEEDING, BUT WHY WOMEN SHOULD BE SUPPORTED TO MAKE AN INFORMED CHOICE ANYWAY
Breastfeeding with an undetectable viral load: what do we know?

I’m not a mother and sometimes I think that when it comes to breastfeeding I should just keep my big trap shut.

I have started and stopped this blog so many times. But I’ve decided to write it and here’s why.

I don’t think women are given enough information about breastfeeding. And I don’t think their choices are respected enough. I believe that women should be empowered to make their own choices about breastfeeding and they should be supported – not policed – in these decisions.

I also believe that women living with HIV are not often given sufficient information about the risks associated with breastfeeding. I’m seeing some voices emerge from the U=U community in support of the idea that U=U applies to breastfeeding. It doesn’t. And failing to look directly at the risks, examine them, and provide a balanced look at the issue is not supportive.

Supporting women to make informed choices on the topic does not mean eliminating information on either side of the argument. It means respecting women’s ability to understand scientific information and sharing that information willingly – instead of just telling them what not to do. And it means supporting women to make choices even when these choices may include small risks.

In this blog post I will explain why the risks are there but also why I believe that women should be supported in making a choice to breastfeed, and why I believe that more information for women is key.

Why do we hear mixed messages about HIV and breastfeeding?

Many HIV+ women I talk to about the topic of breastfeeding express confusion why the guidelines on breastfeeding vary from country to country. Women from Africa or other parts of the world will be encouraged to breastfeed despite their HIV status. From the perspective of an HIV+ woman, why should they be encouraged to breastfeed in Rwanda but not in the UK or Canada?

The answer is that in low-resource settings, where infants may be at higher risk from infant mortality caused by diarrhoea or illnesses related to parasites that may enter the body through foreign substances (unclean water or formula), breastfeeding is the best choice. When weighing the risks and benefits, breastfeeding is the safer choice.

A different approach will be taken in high resource settings where the risks and benefits are also weighed. In the UK or Canada for instance, where there is clean drinking water and formula available, it is a safer choice to simply eliminate the risk of transmission through breastfeeding. In these countries, the risk of HIV transmission outweighs any other risks. Of course, what makes sense from a public health perspective is not always what makes sense for the individual. But I’ll get back to that.

Does Undetectable = Untransmittable apply to breastfeeding?

More and more women are wondering about the role of an undetectable viral load. It seems to be pretty clear than an undetectable viral load does significantly lower the risk of transmission through breastfeeding. It lowers this risk by about 60%. This means that the risk is indeed low! But it is not zero.

When it comes to sexual transmission, we have a good body of evidence that proves that people living with HIV who have a sustained undetectable viral load do not transmit HIV to their partners, even through otherwise unprotected vaginal or anal sex. There has never been a case of sexual transmission from a person with an undetectable viral load. This is why we can unequivocally state, with sexual transmission, Undetectable = Untransmittable. There is no risk, or for the overly cautious, we could at most say there is a negligible one.

Unfortunately, we cannot say this about breastfeeding.

For one thing, there have been documented cases of transmission through breastfeeding when the mother had an undetectable viral load. Two studies showed that in 15% of cases where HIV was transmitted to infants through breastmilk, the mother was undetectable. So while PARTNER revealed zero transmissions, we simply cannot use the same terminology here given that transmissions through breastfeeding have taken place.

But why can infection occur through breastfeeding when it can’t through sex?

There are a few reasons why breastfeeding poses a risk while sexual transmission does not. One reason is that cell-associated virus is responsible for many or most infections through breastfeeding. This is a significant point as viral load testing does not measure cell-associated virus. And, because transmission takes place in an infant’s gut, there are lots of other immune cells that play a role in transmission, which would not be the case in sexual transmission.

Latently infected resting cells, HIV-infected macrophages and lymphocytes, and HIV RNA have all been found in breastmilk from women on treatment and play a role in infection. For example, macrophages and lymphocytes (white blood cells which play a role in the immune system) also facilitate the infection of CD4 cells by helping to transport HIV across the epithelial barriers.

Other reasons for increased risk include that breastmilk contains a lot of CD4 cells; infants are exposed to up to 1 million CD4 cells per day. This allows easy access to CD4 cells for infection. Inflammation caused by, for example, mastitis, breast abscesses, and engorgement, also increase the risk and other sources of infection such as cracked, blistered nipples can also provide another source of infection.

The process of infection through the infant’s gut from breastfeeding is thus quite different from that of sex, not to mention the added risk that comes from the volume of fluid that is ingested! Compared to sexual transmission, there is considerably more exposure to an infant who is guzzling breastmilk day and night for months on end, compared to even the lengthiest chem sex party!

This, and the evidence of transmission, has led researchers to conclude that ‘Indeed, the equation “no detectable HIV-1 RNA equals no transmission,” which correctly applies to sexual transmission and perinatal transmission of, does not apply to breast-feeding transmission.’ (Van de Perre, P., Rubbo, P-A., Viljoen, J., Nagot, N., Tylleskär, T., Lepage, P., Vendrell, J-P., Tuaillon, E. , 2012).

Women should be empowered to make an informed choice.

I believe it is unfair of us to incorrectly state that U=U when it comes to breastfeeding. We are giving women misinformation by doing that. We are not supporting them in understanding the scientific information so that they – for themselves – can weigh the risks and benefits.

Mothers do not have it easy. They face a tonne of pressure and criticism from outside voices, be they scientific, medical, social, cultural, or familial. The same applies to many facets of motherhood, including breastfeeding.

The message that ‘breast is best’ is so heavy handed that it makes it difficult to for mothers to feel anything other than a terrible mother for failing to give their child ‘the best’. Pressures can come both internally and externally – there are cultural expectations, norms and beliefs; emotional and physiological desire, information on the internet, feelings of loss, grief, and guilt, the desire to bond with the baby, the opinions of friends and family, pressure from health and social care organisations, the social construction of motherhood and identity, concern for the baby’s health… and good old HIV stigma. Stigma, both external and internal. Stigma, that can, particularly for women in high prevalence communities, lead to gossip or even inadvertent disclosure of HIV status – which comes with a genuine threat to health and wellbeing.

Still, lots of women will choose to sacrifice everything for their baby, and upon knowing the risks, may choose not to breastfeed.

This is part of making an informed choice, however. It should be up to the woman to weigh the risks and benefits – but that necessitates a proper explanation of the risks and why they exist.

Women with HIV who are considering breastfeeding should be given scientific information about how transmission occurs and the role of the immune system – not just cursory information. I believe that everyone has the capacity to understand scientific information about HIV transmission if it is presented in a clear and thoughtful manner. But how often do we have opportunities to communicate with health practitioners about this?

More often than not, we are simply told not to do something. We are not told how, or why, a risk is present. Only that it’s there.

Supported to breastfeed despite the risks

Here in the UK, women with HIV in the UK are advised not breastfeed their babies even with an undetectable viral load. The British HIV Association (BHIVA) and Children’s HIV Association (CHIVA) Position Statement on Infant Feeding in the UK (2010) states:

‘To prevent the transmission of HIV infection during the postpartum period, BHIVA/CHIVA continue to recommend the complete avoidance of breastfeeding for infants born to HIV-infected mothers, regardless of maternal disease status, viral load or treatment.’

However, in the UK, breastfeeding is not an automatic child protection issue and mothers who breastfeed will still receive support. In Canada, (which also has harsher criminalisation laws), a more hard-line approach is used. I think that the British model is much better.

Even with all of the risks I have described, I still think that women should be able to make the choice to breastfeed.

Why?

1.  While it’s clear that being undetectable does not eliminate the risk of infection as it does in sexual or vertical transmission, it significantly reduces the risk. The risk is low enough that, in my opinion, women should have the option to take this risk.

2.  Women should have the right to make the best decisions about the health of their children. We should have the ability to weigh the risks and benefits and decide for ourselves what is the best decision given the context of our lives. But this means that we should be given more, not less information. I think that HIV+ women should be given more information on the topic – including why the guidelines are different by country, the rates of transmission, and how infection occurs.

3.  Public health decisions are made from a population health perspective, not an individual one. In this case, guidelines are set because the absolute safest thing to do is not to breastfeed. If no mothers living with HIV will breastfeed, we eliminate that risk altogether. If we take our goal of eliminating HIV transmission, this does make sense. But many times this translates to advice that just does not suit the context of our individual lives. As Harvey Pekar wrote, ‘ordinary life is pretty complex stuff.’ For many reasons, we simply cannot always make the safest, or the most optimal choice that is given under advisement of our doctors.

4. In situations where women feel that abstaining from breastfeeding is not possible or simply not the right choice, it’s far better to support women to reduce the risks, such as by providing strategies that can help to lower risk (such as medication adherence, exclusive breastfeeding, avoiding breastfeeding if there is an infection or cracked, blistered nipples, etc.)

Writing this piece may alienate me from either side of the argument. But I am concerned that women may not necessarily have the information nor the support from the medical communities on this subject, nor from wider health and social care or even from HIV/AIDS organisations. The HIV community has an important role to play in listening, training, supporting and advocating on this issue.

Works consulted:

Breastfeeding and HIV International Transmission Study Group, Coutsoudis A, Dabis F, Fawzi W, Gaillard P, Haverkamp G, Harris DR, Jackson JB, Leroy V, Meda N, Msellati P, Newell ML, Nsuati R, Read JS, Wiktor S. Late postnatal transmission of HIV-1 in breast-fed children: an individual patient data meta-analysis. J Infect Dis. 2004 Jun 15;189(12):2154-66. Epub 2004 May 26.

British HIV Association (BHIVA) and Children’s HIV Association (CHIVA) Position Statement on Infant Feeding in the UK (2010)

Canadian Paediatric Society (2017). Testing for HIV infection in pregnancy.

Coovadia HM1, Rollins NC, Bland RM, Little K, Coutsoudis A, Bennish ML, Newell ML. Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study. Lancet. 2007 Mar 31;369(9567):1107-16.

Government of Canada (2015). Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months. A joint statement of Health Canada, Canadian Paediatric Society, Dietitians of Canada, and Breastfeeding Committee for Canada

Gordon, B. Breastfeeding wars: is breast really best? To breastfeed or not to breastfeed? If you feed your baby formula rather than mother’s milk, you’ve probably already felt the disapproval of the ‘Breastapo’. But is breast really always best? The Telegraph 1:20PM BST 20 Aug 2014.

HIV iBase (2015), Guide to HIV, Pregnancy & Women’s Health.

Kennedy, L., Serghides, L., Greene, S. Webinar: A Complicated Dilemma: HIV and infant feeding (2014). www.catie.ca/en/webinar-series-positive-parenting

Khosla, P., Ion, A., & Greene, S. (2016). Supporting Mothers in Ways that Work: A Resource Toolkit for Service Providers Working with Mothers Living with HIV. Hamilton, ON: The HIV Mothering Study Team.

Manigart O1, Crepin M, Leroy V, Meda N, Valea D, Janoff EN, Rouet F, Dequae-Merchadoux L, Dabis F, Rouzioux C, Van de Perre P; Diminution de la Transmission Mere-Enfant Study Group. Effect of perinatal zidovudine prophylaxis on the evolution of cell-free HIV-1 RNA in breast milk and on postnatal transmission. J Infect Dis. 2004 Oct 15;190(8):1422-8. Epub 2004 Sep 9.

O. Manigart, M. Crepin, V. Leroy, N. Meda, D. Valea, E. N. Janoff, F. Rouet, L. Dequae Merchadoux, F. Dabis, C. Rouzioux, P. Van de Perre; Diminution de la Transmission Mere-Enfant Study Group, Effect of perinatal zidovudine prophylaxis on the evolution of cell-free HIV-1 RNA in breast milk and on postnatal transmission. J. Infect. Dis. 190,1422–1428 (2004).

Overbaugh, J., and Milligan, C. (2014, December 14). The Role of Cell-Associated Virus in Mother-to-Child HIV Transmission. Journal of Infectious Diseases. 210 (suppl 3).

Public Health England (2015). HIV in the UK – Situation Report 2015.

Royal College of Midwives. (2014). Infant Feeding: Supporting Parent Choice.

Royal College of Nursing. (2016). Formula feeds: RCN guidance for nurses caring for infants and mothers.

UNICEF UK (2012). Guide to the Baby Friendly Initiative Standards.

Van de Perre, P., Rubbo, P-A., Viljoen, J., Nagot, N., Tylleskär, T., Lepage, P., Vendrell, J-P., Tuaillon, E. (2012). HIV-1 Reservoirs in Breast Milk and Challenges to Elimination of Breast-Feeding Transmission of HIV. Science Translational Medicine. 118 July Vo 4, Iss.143.

World Health Organization. (2016). Guideline: updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV.

World Health Organization. HIV/AIDS: Mother-to-child transmission of HIV.  

HIV Positive Smokers Who Quit Cut Their Risk of Numerous Cancers

However, unlike HIV-negative quitters, their lung disease risk remains highly elevated for at least five years after kicking the habit.

If people living with HIV who smoke quit their cigarette habit, they soon cut their risk of numerous cancers, aidsmap reports. However, unlike HIV-negative people who quit smoking, HIV-positive ex-smokers maintain a much higher, non-declining risk of lung disease for at least five years to follow.

Researchers from the D:A:D cohort analyzed data on all the HIV-positive participants’ cancer incidence between 2004 and 2015. They compared the cancer rates between those who currently smoked, never smoked, who had quit cigarettes before entering the study and who quit during the study.

Findings were presented at the 2017 Conference on Retroviruses and Opportunistic Infections (CROI) in Seattle.

A total of 35,424 participants, 46 percent of whom were smokers and 20 percent of whom were ex-smokers, were diagnosed with 1,980 cancers between them, including 242 lung cancers, 487 other cancers considered related to smoking and 1,251 other cancers not considered related to smoking.

The notable proportions of cancers occurring in each of the four groups of participants were as follows: lung cancer, 70 percent among current smokers and 21 percent among ex-smokers; other smoking-related cancers, including head and neck, esophageal, stomach, pancreatic, kidney and urinary, ovarian and liver cancer, 52 percent among smokers and 21 percent among ex-smokers; cancers not related to smoking, 47 percent among smokers and 20 percent among ex-smokers.

The researchers found that for about the first year or so after quitting cigarettes, the participants’ risk of smoking-related cancers, save for lung cancer, fell dramatically and after that hit a level comparable to that of nonsmoking people with HIV. This drop in risk was unaffected by participants’ age, CD4 count or sex.

With regard to lung cancer, after the researchers adjusted the data for various factors, they found that the risk remained 8.26-fold higher for ex-smokers for as long as five years after they quit cigarettes compared with HIV-positive never smokers. HIV-negative smokers, on the other hand, start to realize a decline in risk of lung cancer within five years of quitting.

Breast Feeding and HIV – another interesting and relevant paper from CROI

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.  This post comes directly from the ASHM website and this is is an important issue that still can be and is surrounded by controversies, depending on where in the world you are, so I thought it important to share this with you.

Greetings from Seattle, the Emerald City, Washington.

It’s 8pm on 11/2/17 (or 2/11/17 depending on your preference) and it’s currently a brisk 48oF (9oC) compared to 44oC at home yesterday.

My initial impression on arriving in Seattle was the apparent anti-Trump sentiment in the Pacific North-West evident from the graffiti on the wall on the way from the airport announcing “STOP TRUMP”, to the Washington state legal action against the travel ban, which is currently underway.

Day 1: Today I attended the 7th International Workshop on HIV and Women, a small workshop with a select audience of 120 registrants, 10% being men. The major focus of this meeting is to present the latest data on HIV as it affects women and most importantly to promote a dialogue and interaction between participants.

Session 1 focussed on current controversies in breastfeeding – related basic science, clinical trial evidence was presented and the session concluded with a debate on the pros and cons of breastfeeding in the context of HIV.

Infant feeding is a complex issue and related choices by an HIV infected mother should always support prevention of HIV transmission, provide greatest nutritional benefit and prevent the infant experiencing significant non-HIV morbidity and mortality eg from diarrhoeal diseases.

There are many factors which can influence transmission of HIV via breast milk which I will not elaborate here.  Note that some studies have shown that mothers with undetectable HIV RNA in the blood can still transmit HIV in breast milk because antiretroviral drugs do not pass into breast milk with full, equal efficacy.  Studies indicate passage of NNRTIs into breast milk of 80%, PIs 20%, and there is no passage of Integrase Inhibitors (in the one paper to date).  Further sub-optimal drug levels of ARVs in breast milk may contribute to drug resistance in the infant. There is also a different viral load in breast milk between each breast. Recent trials (Mma Bana and PROMISE Study) indicated risk of MTCT from breast milk was 0.3% in the context of ARV treatment. However, we do not know what may be the best ARV regimen for breast feeding mothers.

It is very important to be aware of the latest WHO Guidelines which were updated on 01/08/2016. I draw your attention to these new guidelines as they do now have more relevance to developed world settings.  The WHO Guidelines have usually been intended for countries with high HIV prevalence, and there is not wide adoption of the WHO Guidelines in highly developed countries, and of course there are longstanding regional guidelines in operation – eg US Guidelines (last updated October 2016) where breast feeding is not recommended (AII), with guidelines from other regions – BHIVA/CHIVA, Australia, Canada (CAPG and SOGC) being similar.

In a number of developed world settings, women are starting to breast feed in the context of full virological suppression and infant post exposure ARVs (including triple therapy!) and there are some emerging case reports on outcome. In many instances women are breast feeding without their health providers knowing.

Canada is now developing a national policy document relating to the follow-up of women who have breast fed their infants.  Further, be aware that Switzerland is now starting to allow breast feeding for women with an undetectable HIV viral load and the identified cohort will be followed prospectively.

It is increasingly apparent that there is a now an emerging dilemma as to whether we can start to recommend breast feeding by mothers with HIV infection in all settings.  Are we reaching a point now in our clinical practices, where there is sufficient safety data to consider supporting breast feeding?  A recent survey of health care providers suggests that nearly 50% of health care providers would consider offering a breast-feeding option regardless of speciality.  This is in the context of a background prevailing attitude of health providers which is, quite understandably, zero tolerance for any infant HIV acquisition. There was also acknowledgement that there is an evolving professional tension in some settings, between Paediatric ID clinicians and maternal HIV clinicians and a tendency for there to be “policing of mothers” in the community and by some health providers.

The outcome of the debate on these issues in this session, was that it is time for there to be a more open discussion between women living with HIV, in a “shared care” arrangement with their health provider, on the risks and benefits of breast feeding.  This discussion must also emphasise maintaining adherence and full virological suppression, as studies have shown a decline in adherence in the post-partum period.  The session also concluded that there needs to be a relevant dialogue between health care providers and the development of governmental or professional organisational guidelines to assist health care providers in offering a breast feeding option.

HIV podcast series by BBC Health Check

I’m a baby of the 80’s. In the early days of the epidemic I wasn’t old enough to remember the ravages of HIV. The invention of triple-drug therapy in 1996 and free access to treatment via Medicare has undeniably saved my life, a luxury many diagnosed before me did not have. As a member of a younger generation effected by HIV in Australia I believe it’s important to have insight into the history of HIV and recognition of the challenges and successes other countries face, often amongst differing political ethos and limited resources.

This month the BBC World Service, Health Check has put together 5 podcasts on the global response to HIV called “The Truth About AIDS”. It explores the history of the HIV epidemic and the varied global response. You can download and listen to the podcast below.

Episode 1: The Fight Against AIDS (27 mins) explores the medical breakthroughs which have transformed HIV from a death sentence to a chronic manageable disease. In June 1981 the first documented cases were recorded in the US yet it wasn’t until four years later a blood test became widely available. Dozens of potential anti-HIV drugs were tested unsuccessful, until finally, dramatic results were seen in the first zidovudine (AZT) trials. Community activisms in the US lead to the AIDS Coalition to Unleash Power (ACT UP) demanding quicker access to experimental drugs. The development of new drug classes in the early 1990’s further reduced HIV viral loads in clinical studies. This lead to a historical announcement that treating HIV with a combination of drugs from different drug classes significantly reduced AIDS deaths. However international trade agreements prevented the sale of cheap generic HIV medication to the continent where it was most needed, Africa.

 

Episode 2: Britain and America (27 mins) discusses the biggest health campaign in the UK since World War II with the 1980’s Minister for Health, Lord Norman Fowler. This is starkly contrasted against the US’s slow political response and continual ban on funding for public health prevention strategies that work.

 

Episode 3: Russia and Australia (27 mins) describes HIV preventative strategies that are known to work at reducing new HIV rates. Australia is considered a world leader in its quick response to implementing clean needle exchange, decriminalisation of sex work and strong political leadership which drove through prejudice and out dated attitudes. In comparison, Russia continues to deny its burgeoning HIV epidemic, spurred on by intravenous drug use. Clean need exchange and methadone programs are not legalised and people living with HIV struggle to access treatment.

 

Episode 4: The Truth About AIDS in Uganda (27 mins) acknowledges Uganda was the first African country to discover HIV and by 1994 18% of the population was HIV+. Since then the country has made significant headway reducing new infection, with a 70% reduction in mother-to-child transmission. This is been possible with funding from international donors, including PEPFAR and the Global Fund. Most clinics are provided in urban areas and there are continual gaps in rural service delivery. Community initiatives, such as the Stigmaless band are vital in reducing stigma and teaching HIV education using the medium of song “adherence is the key to success, take your drugs and victory will be yours”.

 

Episode 5: Manilla (27 mins) is the capital of the Philippines, a conservative Roman Catholic country. The key themes of this podcast explore the stigma of being homosexual and the ‘loss of face’, shame and denial of being HIV+. Dr Margarita Holmes examines ethical and personal dilemmas, including the taboo of talking about sex.
Interestingly, this episode also explores the ban on PLHIV travelling and working the UAE. A mandatory HIV test for a work permit, followed by a HIV+ result sees a Pilipino man detained for a month in a ‘quarantine area’ described as a prison cell, with people kept in handcuffs and chains while waiting for deportation.

New Year Resolutions

new yearLove them or hate them, stick to them or ditch ‘em, New Year resolutions are common talk around this time of year. We promise ourselves acts of self-improvement or doing something nice for others, yet whether they last really depends on our level of motivation.

I consider managing my HIV to be a worthy resolution. Every year I promise myself to remain engaged in clinical care and adhere to my HIV medication. It might seem like a no brainer, but for me after years and years of living with HIV it really does take a back seat to what’s going on in the rest of my life.

Wherever you are on your HIV journey perhaps you can make a New Year resolution about managing your HIV in 2015?

Things you can do to get on and stay on track:

    • Start HIV treatment (if you haven’t already). Studies prove starting treatment regardless of CD4 count has significant benefit to your health, reducing viral load and onward transmission.
    • Adhere to your medication, set an alarm (if like me you get a bit forgetful)!
    • Write down scheduled hospital and GP appointments in your diary, calendar or smartphone. If you’re worried someone might look you could write these in code, i.e. Coffee with Fiona (aka Fiona Stanley Hospital).
    • Work out in advance medication refills. Nothing is worse than stressing you don’t have enough tablets to get you through to Monday!
    • Keep up with regular blood tests, typically every time you collect a new script. This is the only way of knowing the HIV medication is working correctly and you have an undetectable viral load (UVL)
    • Foster a good relationship with a HIV clinician/GP, one where you feel there is a partnership and are confident having a two-way conversation.
      Get help & support for other concerns such as financial vulnerability, mental health, substance use or unstable housing in order to help you fully engage with medical care and adhere to HIV treatment.

Perhaps if you need some help to get started you could schedule an appointment with a support officer at WAAC on 9482 0000. Good luck and let’s kick start our HIV management with a bang in 2015!!!

Heather Boerner’s – Positively Negative: Love, Pregnancy, and Science’s Surprising Victory Over HIV

PositivelyNegativeCoverConceiving a child when one or both partners are HIV-positive used to be the stuff of dreams, but today, modern science allows couples to give birth to HIV-negative babies a reality. A short ebook ‘Positively Negative’ by Heather Boerner sheds light on the developments of reproductive health for those living with HIV and the desire amongst adversity to have a family of one’s own. As Boerner describes it “in both straight couples, the man has HIV, and the women and children remain HIV-negative despite having unprotected sex”.

‘Positively Negative’ guides readers on a 15 year long journey, exploring the reproductive decisions of couples in the U.S. and their different assessments of HIV risk acquisition amongst the landscape of emerging HIV research and treatment development. Historically HIV-positive heterosexuals were discouraged from having children and in the early days pregnant women were encouraged to have abortions. Options for serodiscordant couples (in which one partner is HIV-positive and the other HIV-negative) included adoption, the use of donor sperm or egg, or surrogacy. As early HIV treatment became available more options were offered including sperm washing (using chemicals and a centrifuge to separate the sperm from the seminal fluid) with in vitro fertilization (IVF – the process in which the egg is fertilized outside of the body) or intrauterine insemination (IUI – inserting the prepared semen through the cervix into the uterus), however both were expensive and often difficult to access.

The shining light in this story is how Boerner masterfully intersects two key pieces of modern HIV research into the lives of HIV serodiscordant couples trying to conceive.

  • The Swiss Statement by Dr Pietro Vernazza (2008) from the Swiss Federal Commission for HIV/AIDS stated a HIV-positive heterosexual person is not sexually infectious if:
  • The HIV-positive person had an undetectable viral load (VL < 40 copier/ml) for at least 6 months
  • The HIV-positive person adheres to their daily treatment and was regularly monitored
  • The heterosexual couple were in a monogamous relationship
  • Both partners had no other STI’s

HTPN 052 by Myron Cohen et al. (2011) Prevention of HIV-1 Infection With Early Antiretroviral Therapy

  •  Early initiation of antiretroviral therapy (ART) in HIV-positive individuals reduced the rates of sexual transmission and clinical symptoms, indicating both personal and public health benefits
  • ART reduced the risk of heterosexual transmission by 96%

In the book Boerner follows Susan & Dan Hartmann. They had unprotected sex only when Susan was ovulating and Dan adhered to HIV medication and consistently had an undetectable viral load. Susan meticulously kept calendars and used ovulation-testing kits. They reassessed this process 6 monthly and Susan had the right to refuse unprotected sex at all times. They also openly discussed what it would mean if Susan contracted HIV. It took just two months for the pregnancy test to come back positive. Susan remained HIV-negative. In 2009 their HIV-negative daughter Ryan Nicole was born.

Boerner also followed Ted Baker and Poppy Morgan. They also had unprotected sex with Ted adhering to his HIV medication and consistently having an undetectable viral load. In addition, Poppy took Truvada as a Pre-Exposure Prophylaxis (PrEP) medicine, approved to prevent HIV-negative people from contracting HIV. Poppy continues to keep a blog of their experiences HIV-negative spouses In 2013 their HIV-negative daughter nicknamed Pom-Pom was born.

Some people uneducated about modern HIV treatment may think people living with HIV trying to conceive should not be allowed to have condomless sex. However the evidence is clear and with consistence clinical care there is minimal risk. Both couples in this story were responsible risk takers and their foray into ‘wild unprotected sex’ was instead highly structured.

Boerner also touches on stigma and recognises a difference around fear of the HIV virus between generations. Caroline Watson, born in the late 80’s says:

As long as you’re taking care of it, you’re not going to get sick, you’re not going to get AIDS and you’re not going to die of it.” What you will die of, she said, is shame: People who are ashamed of having the virus don’t go to the doctor and don’t take their medicine. People who are ashamed don’t tell their partners, and put them at greater risk of infection.

While Boerner herself admits to “having grown up in the 80’s, and remembering how terrifying the early virus was, my entire sexual life developed around fear of the virus. As a girl, I wasn’t just afraid of getting pregnant. I was afraid that any little slip up and I could be that girl in a wheelchair in my 20s, dying.” “The more I listened to Watson’s staccato, matter-of-fact cadence as she talked about her approach to the virus, the more I realised that the problem is with me and the rest of us whose image of the virus froze in the 1980s.”

This ebook is a fantastic read not only for serodiscordant couples, but anyone living with HIV, the clinicians, GPs and nurses who treat them and the wider community who are interested in HIV. It sheds light onto the emotional and medical struggles to conceive an HIV-negative child in a time when HIV is classified as a chronic illness and HIV-positive people have a normal life expectancy. Perhaps the only let down is Boerner not following a HIV-positive woman in a serodiscordant relationship conceiving and giving birth to an HIV-negative baby. However, in Boerner’s words ‘it is a story of how super-powerful HIV medications have changed the social landscape as well as the medical one. It is a story of risk and possibility, of the promise of family and the fear of a resurgence of the virus’.

If you are HIV+ and interested in starting a family discuss your options with your HIV clinician 

You can find ‘Positively Negative: Love, Pregnancy, and Science’s Surprising Victory Over HIV’ [Kindle Edition] by Heather Boerner here

Check out these links for further information: