Recent advances in a number of research fields, particularly the antiretrovirals (ARVs) have largely transformed HIV/AIDS from a painful death sentence to a manageable illness. And additional advances in peripheral fields like gene therapy, vaccines, cellular manipulation, etc., actually have immunologists and researches using the word “cure” without fear of being tagged as irresponsible pipe-dreamers. However, so far the hypothetical end-product of most of these research paths have been qualified as “functional cures”.

A functional cure is generally defined as one in which the virus has been beaten into harmless remission and remains there without the need for adhering to an expensive drug regimen.

While remission and freedom from reliance on the cocktail is nothing to turn one’s nose up at, even the most effective treatments leave concentrations of the HIV virus lingering in the body. These viral “reservoirs” (or “latent reservoirs”) are problematic chiefly because in most HIV-positive people, when drug therapy stops, those reservoirs soon flood the body and the immune system is once again attacked. To affect an actual cure, the viral reservoirs in the brain/central nervous system, gut and other common retreats for dormant HIV must be flushed out where it can be killed by ARVs. If not, relapse is a near certainty. Researchers are working to find flushing agents on several fronts. Here are some of the most promising:

HAART. Dr. David Ho is probably one of the two biggest names in HIV research; the other being Dr. Robert Gallo. 1996 Time Man of the Year Ho has dedicated a considerable portion of his career to highly active retroviral therapy (HAART). HAART treatments block the action of reverse transcriptase and protease - two enzymes necessary to HIV’s replication and cell infiltration. Ho believes that if a patient strictly abides by their HAART drug regime even the viruses hiding in the latent reservoirs could be disabled and eliminated in roughly six years.

Drawbacks. As is the case with any powerful drugs, the HAART cocktail’s side effects can be rough and even dangerous. Plus, a sizable chunk of those committed to HIV research insist that no drug therapy can eradicate the virus entirely.

HDAC Inhibitors or HDIs. Histone deacetylase inhibitors (HDACs or HDIs) have long been used as mood-stabilizers and anti-epileptics and more recently have proved promising for battling cancer. Within the past few years, however, they’ve come to the attention of immuno-virologist specialists for their apparent efficiency at highlighting and purging dormant HIV from the cells concealing them. The two being most actively investigated are vorinostat and valproic acid.

Drawbacks. Once again, while the results emerging from very small-scale clinical trials has been promising, use of HDIs in the fight against HIV is new and they may prove prohibitively toxic. Aforementioned HIV pioneer Dr. Robert Gallo (among others) further warns that there is no 100% guarantee that all of the flushed virus will be dead or killed. If the HDIs don’t work as is hoped, they could actually contribute to the establishment of more entrenched latent reservoirs in the brain.

Disulfiram. In another strange case of drugs better known for their use in the treatment of unrelated, psychiatric/neurological disorders (and perhaps cancer), the drug disulfiram is both better known as Antabuse and for its use in the treatment of chronic alcoholism by creating an acute sensitivity to alcohol. In the lab and limited clinical trials, though, disulfiram did exhibit potential as a reservoir-draining latent HIV activator.

Drawbacks. Over the long term, disulfiram trials saw a reservoir-depletion of around 14%; which is statistically insignificant. However, researchers found that it was efficacious in short-term latent viral activation and was well tolerated, meaning it could be incorporated into a broader treatment strategy. The most troubling drawback, of course, is that one couldn’t drink during disulfiram treatment!

Prostratin and DPP. Prostratin and its chemical cousin DPP are poignant arguments for the preservation and study of forests and traditional medicinal practices around the world. They are chemicals initially derived from the bark of the Somoan mamala tree, a resource locals have been using to battle blood disorders for years. Early research into prostratin and DPP’s viability as a latent HIV activator and reservoir-depletion mechanism has been encouraging.

Drawbacks. Synthesizing prostratin and DPP have proved difficult considering the rarity of their source material and relative newness of their appearance. That newness is another drawback as possible side-effects, long-term repercussions and long-term effectiveness are not well known.

As hopeful as the prognosis is for any or all of these treatments, virtually all scientists point out that this sort of research is in its relative infancy. It’s also a branch of HIV-eradication medicine that is something of an all-or-nothing proposition. Even an effectiveness of 95% is five percent too little.

Guest writer Jim Fox is a freelance writer who studied medicine for his undergraduate degree. He frequently writes about topics pertaining to the medical industry, including affordable RX drugs.  When he isn't typing the day away, Jim is either perfecting his wine recipes or lacing up his ice skates and heading for the nearest frozen water.

Bob Leahy: James, you gave a presentation at the Gay Men’s Sexual Health Summit in Toronto last week on Understanding and Communicating Risk: Viral Load and HIV Transmission. That’s a topic that fascinates us here, and one we’ve been following on PositiveLite.com for some time. Clearly it’s important for people living with HIV to have the best possible understanding of this too.  With this in mind, thank you for agreeing to talk to PositiveLite.com and helping us understand more.

I guess we should start with the basics.  Tell us what an undetectable viral load means in plain language.

James: Undetectable basically means that the amount of virus (also known as the viral load) in a body fluid is below the limit that our viral load tests can detect. Viral load is regularly measured in the blood to monitor how well treatment is working for someone living with HIV. Generally, successful antiretroviral treatment can reduce the blood viral load to undetectable levels within a few months of starting. In Canada, an undetectable blood viral load normally means that there are less than 40 copies of the virus per ml of blood. Tests to detect the amount of virus in other body fluids such as semen, vaginal fluid, and rectal fluid, are not available to people living with HIV but have been developed for research purposes.

Bob: So a person with a lower viral load is likely less infectious than one whose viral load isn’t under control?

James: A lot of research shows that a lower viral load in the blood is generally associated with a lower risk of sexual HIV transmission. Although blood isn’t a fluid that’s often involved in the sexual transmission of HIV, the viral load in the blood is generally correlated with the viral load in the fluids that are, such as semen, vaginal fluid, and rectal fluid. In other words, if the viral load is controlled in the blood, it’s also generally controlled in those other body fluids. However, this isn’t always the case and some people living with HIV can have detectable amounts of virus in the genital and rectal fluids even though the viral load is undetectable in the blood. This is more common if someone has a sexually transmitted infection (STI) but can also happen when there isn’t an STI.

It’s important to note that pretty much ALL the research that has been done to date around viral load and HIV transmission has been among heterosexual couples.

Bob: I guess the big question is HOW MUCH less infectious and how we communicate that risk so that people can make decisions appropriate to their own situation? There is research from last year that made international headlines - HPTN 052 – with its conclusions that in the right circumstances, the chance of transmission in sero-discordant (heterosexual) couples was reduced by 96%.   Can you comment on how important was that study in trying to understand our own risk?

James: There are two different pieces of information people living with HIV normally want to know with regards to antiretroviral treatment, viral load, and the risk of HIV transmission. The first is HOW MUCH treatment can reduce their risk of transmission, also known as the relative-risk reduction. The second is HOW LOW that risk is reduced to when they are on treatment, also known as the absolute risk of transmission. People living with HIV are often most interested in the latter; their absolute risk of transmitting HIV when they are on treatment and have an undetectable viral load.

Unfortunately, biomedical HIV prevention trials such as the HPTN 052 study are not designed to provide information on an individual’s absolute risk of HIV transmission. These trials tell us about the change in risk of HIV transmission in a population using an intervention relative to a “control” population not using the intervention, in other words the relative risk-reduction. The relative risk-reduction is important to know because it tells us how effective a strategy is at reducing the risk of HIV transmission and can be used to compare the effectiveness of one strategy to another. The 96% relative risk-reduction calculated in the HPTN052 study tells us that antiretroviral treatment is highly effective at reducing the risk of HIV transmission among heterosexual couples who are mostly having vaginal sex.

However, the relative risk-reduction is not something that an individual can use to easily assess their absolute risk of HIV transmission. It’s really difficult to quantify someone’s absolute risk of HIV transmission while on treatment because it depends on a number of different factors unique to an individual such as how often they are having sex, how often they are using condoms, how well they are adhering to treatment, if they have any STIs, and the type of sex they are having. Therefore someone’s absolute risk of HIV transmission while on treatment may be higher or lower than another individual on treatment. We really need studies that try to calculate the absolute risk of HIV transmission from a single exposure to HIV through different types of sex (when the viral load is undetectable).

In the absence of additional information on absolute risk and in the face of these uncertainties, there are still messages that we can give to individuals so they can make informed choices and keep their risk of HIV transmission as low as possible while using “treatment as prevention.” This includes using condoms correctly and as often as possible, adhering to meds, regular viral load testing and regular STI testing and treatment for STIs.

Bob: Of course that leaves gay men a little in the dark doesn’t it, because that HPTN 052 data doesn’t necessarily reflect the realities of the risk associated with anal sex, for instance?

James: There is a much larger research gap when it comes to gay men.

We really don’t know if the relative risk-reduction while on treatment will be the same for gay men as for heterosexual couples. However, researchers think that it could be similar.

Even if the relative risk-reduction is the same for gay men, the absolute risk of HIV transmission while on treatment may be higher for gay men (who are having anal sex) than for heterosexual couples (who are mostly having vaginal sex). We know that bottoming without a condom (unprotective receptive anal sex) is up to 20 times more likely to lead to HIV transmission than unprotected receptive vaginal sex. Therefore, the higher initial risk associated with anal sex may mean that the absolute risk of HIV transmission when undetectable is much higher for anal sex than for vaginal sex.

The 96% relative-risk reduction from being on treatment is equivalent to approximately a 20-times reduced risk of HIV transmission. Furthermore, when not on treatment, we know that the risk of HIV transmission through bottoming is up to 20-times higher than vaginal sex. Therefore, if being on treatment reduces the risk of HIV transmission through bottoming by 20-times, the absolute risk of HIV transmission after this reduction in risk may still be in the same range as vaginal sex when not on treatment. 

This is all hypothetical and really emphasizes the need for more research

Bob: So the message here is that we need more research in to the impact of undetectable viral load on MSM, right?  Is anything going on?

James: Yes, we need more research. I know of some that’s going on in Australia and the Netherlands, hopefully we will see some results at the next International AIDS Conference in Washington this summer.

Bob: Let’s talk about risk guidelines for a moment.  Tell us how risk factors – percentages like 96% - are ultimately translated in to low-high risk language. What degree of certainty needs to be in place before they are formulated in this way?

James: There is no guide for translating risk-reduction percentages (relative risk reduction) into low-high risk language (absolute risks). The CAS Transmission Guidelines do not use risk-reduction percentages to determine which activities or behaviors should be placed into “high” or “low” risk categories. The CAS Transmission Guidelines were developed when our knowledge of HIV was much more limited. At the time the guidelines were developed, we knew that unprotected vaginal/anal sex was significantly more risky than oral sex and that condoms could significantly reduce that risk. It was this knowledge that formed the basis of these guidelines.

In the past decade there has been a significant amount of research emerging around the biology of HIV transmission and new HIV prevention technologies. It’s only recently that we have had to deal with these relative risk-reduction percentages and we really haven’t figured out the best way to incorporate all this information into our discussion of risk. It’s difficult because the use of “treatment as prevention” and other new prevention options have a number of caveats and uncertainties and there are still large gaps in the research.

Bob: So in the case of risk guidelines which include reference to undetectable viral load, we don’t yet have that degree of certainty? What about for heterosexual couples?  Isn’t the data strong enough there for risk guidelines to be in place, based on HPTN 052, do you think?

James: There is strong evidence that being on treatment and having an undetectable viral load significantly reduces the risk of HIV transmission for heterosexual couples. However, simply saying that the risk is “low” doesn’t reflect some of the caveats and uncertainties of this approach or the research gaps that exist, particularly among gay men.

We definitely need the latest science to be incorporated into guidelines so people are getting accurate information on “treatment as prevention” and this information is accompanied by the appropriate messages to keep this risk as low as possible. This information is already starting to show up in different guidelines, including treatment guidelines which are suggesting that physicians discuss the role of treatment as prevention with patients. Mostly people are considering undetectable viral load as an additional strategy for HIV prevention, along with regular condom use. However, the HPTN 052 study was only released last year and there is still a lot we don’t know. We are still trying to figure out how to communicate this information and incorporate it into different guidelines.

Bob: You’re probably aware that all this is a bit frustrating for some poz folks. Community leader and POZ magazine founder Sean Strub, for instance questions  (Five Things  about HIV They’re not Telling You)  the risk associated with undetectable viral load and what we are being told.  Strub says “We have neglected to recognize the extent to which a person who is on treatment and undetectable is rendered non-infectious.”  How fair a statement do you think is that?

James: Well first of all we need to avoid using the term non-infectious. There is a general consensus that the risk of HIV transmission is not eliminated when the viral load is undetectable.

Among people who are well versed with the research, I think most agree that being on antiretroviral treatment and having an undetectable viral load significantly reduces the risk of HIV transmission for heterosexual couples.

I don’t think that information is being withheld, we just don’t have a consensus yet on what we should be saying. For most people, the research that we have only provides partial answers to the key questions and this information is difficult to communicate accurately because of the caveats and uncertainties. There are no simple messages yet that applies to everyone. There is the potential for a lot of misunderstanding to occur which could have negative consequences. A major concern is that people may switch from the correct and consistent use of condoms to a strategy that is less protective.

However, I do think we need to acknowledge that not everyone consistently uses condoms (for a variety of reasons) and these individuals need accurate messages on other ways to reduce their risk of HIV transmission, including “treatment as prevention.”

Bob: Strub also talks about the relative risk associated with undetectable viral load and the use of condoms, saying that undetectable may afford the greater protection of the two. When I interviewed Dr Julio Montaner he said much the same thing “I think you should be fully comfortable with advising fully suppressed individuals on HAART that they are as well protected as when using condoms, if not better protected” is what he said to me.   What do you think of these comparisons?

James: I think we need to be careful when we make comparisons to condoms because these are two very different strategies and both have their own caveats.

We also have to make sure we aren’t always pitting condoms against “treatment as prevention” and creating an either/or situation. Both can fail to prevent transmission in their own ways and using both in combination may add an extra “backup” layer of protection.

We know that if a condom is used consistently and correctly (and the condom doesn’t break, slip or leak), then the risk of HIV transmission is pretty close to zero because no exposure to HIV can take place. HIV cannot pass through the material that is used to make condoms. Of course, condoms are not without their own caveats. Condoms aren’t always used consistently and there are lots of ways in which condoms can be used incorrectly. Also, we know that a condom can break even if it’s used correctly.

The use of “treatment as prevention” is different and there are more uncertainties. Unlike condoms which prevent an exposure occurring in the first place, “treatment as prevention” aims to reduce the risk that an exposure leads to infection. Since an exposure is occurring, other factors that influence the risk of HIV transmission from an exposure also come into play and may decrease the effectiveness of this strategy. For example, we know that tearing and inflammation, anal sex, and other STIs can increase the risk of HIV transmission from an exposure and therefore may increase the risk of transmission when the viral load is undetectable.

Also, with “treatment as prevention” you are relying on the viral load in the body fluids to be undetectable. However, it’s difficult to know what the viral load in the blood is at any given time and it’s even more difficult to know what the viral load is in the genital and rectal fluids. In addition, undetectable doesn’t mean that there is no virus, so there is still HIV present that could lead to transmission. All these uncertainties make it very difficult to know if, and how well, this strategy will work.

So which is more effective: Condoms or “treatment as prevention”? It really depends on the individual, their risk factors and how well they are able to use the prevention strategy. We know that both are highly effective in reducing the risk of HIV transmission through vaginal sex if used consistently and correctly. In this case, some people may find the consistent and correct use of one option easier than the other and therefore that option may be more effective for them.

However, if used consistently and correctly, condoms are the still most reliable and effective strategy available because they prevent an exposure from occurring in the first place and there are fewer uncertainties and caveats associated with condoms compared to the use of “treatment as prevention.” Also, condoms can lower the risk of HIV transmission to the same level for anal and vaginal sex while the risk of HIV transmission may be higher for anal sex than for vaginal sex while using “treatment as prevention.”

In the end, HIV prevention needs to help individuals adopt strategies to reduce their risk of transmission that are appropriate to their individual circumstances and the acceptable level of risk they and their partners are willing to take. We definitely need guidelines for people who want to use “treatment as prevention” and are willing to accept the risk that comes along with its uncertainties. These guidelines need to include important messages that can help a person keep the risk of HIV transmission as low as possible while using “treatment as prevention”.

Bob: I want to turn to what we know about semen. Almost every prevention message you see discussing undetectable warns that undetectable viral load in the blood doesn’t necessarily translate to undetectable viral load in the semen. But isn’t it true that in more cases than not there is that correlation?

James: Many people who have an undetectable viral load in the blood also have an undetectable viral load in the semen and other bodily fluids. However, studies suggest that this isn’t always true. The percent of people in these studies who have an undetectable viral load in the blood, but a detectable viral load in the semen, ranges widely, from 3% to 48%. Similar studies suggest that the same also applies to vaginal and rectal fluid.

We really need more research to gain a better understanding of how common this is, and why it happens, among people living with HIV who are undetectable in the blood.

Bob: How about the amount of viral load in the semen?  Isn’t it true that where it IS detectable in the semen but not in the blood, the viral load in the semen isn’t typically very high, the research seems to indicate, and thus not very infectious?

James: Most research has looked at the association between the risk of HIV transmission and the viral load in the blood, not the viral load in other fluids. This means we don’t really know what a “high” viral load in semen (or other bodily fluids) is in terms of infectiousness.

We do know that, in some cases, the amount of virus in the semen (among people who are undetectable in the blood) can be quite a lot higher than undetectable, over 5000 copies/ml. This difference may be quite significant in terms of HIV transmission but we don’t really know and need more research in this area.

Bob: Do you think we are moving towards a place in time when we will see risk guidelines which take in to account the impact of undetectable viral load?  Any guesses when that might be?

James: I definitely think we need to move in that direction. I know of a lot of organizations in Canada that are reviewing the evidence and discussing what their key messages need to be around viral load and risk of HIV transmission. In terms of guidelines from Public Health, I am not sure when those will come. It’s difficult because there are lots of research gaps and the research is still emerging quickly.

Bob: In the meantime it’s being argued before the Supreme Court that a person with undetectable viral load translates to extremely low risk of transmission.  Do you think that has the potential to confuse people living with HIV?  If so what can be done to end that confusion?

James:  The Supreme Court is considering what constitutes a “significant risk” of HIV transmission under criminal law. We need to keep in mind that criminal negligence is a serious charge and the burden of proof is different than it is for public health messages.

We know that the evidence shows that the risk of heterosexual HIV transmission is significantly lowered when someone is on antiretroviral treatment and has an undetectable viral load. Whether this risk is lowered to below what the law defines as a “significant risk” to be considered criminally negligent is up to the Supreme Court.

The court’s decision shouldn’t change the prevention messages we give to people living with HIV who want to use “treatment as prevention.” Regardless of the court’s decision, we still need to inform individuals that treatment does not eliminate risk, there are a number of caveats associated with this approach, and there are certain things an individual can do to keep this risk as low as possible. We will also, of course, need to inform people living with HIV who want to use this as a prevention strategy about the law and any changes that happen with the Supreme Court decision.

Bob: James, thank you so much for talking to us.

James is the coordinator of the Biomedical Science of HIV Prevention Project at the Canadian AIDS Treatment Information Exchange (CATIE) where his work focuses on the biology of HIV transmission and new HIV prevention technologies.

This is the second of three articles by PositiveLite.com writers on “what undetectable means to me.” Read Bob Leahy’s earlier take on this topic here.  Wayne Bristow will follow later this week.

Three months after I started anti-retroviral therapy (ART), I got a call from my doctor. Even though my next appointment with him was still a week away, he phoned me because he wanted to give me the good news right away. My lab results had just come back showing that my HIV viral load had reached an undetectable level.

He was excited for me and I was excited myself. Why? Because the goal of HIV treatment is to reduce the amount of virus in the blood to a level so low that it cannot be detected by the standard tests. Being “undetectable” confirmed that ART was working for me. HIV had been stopped in its tracks; it’d been defeated in its attempts to damage my immune system. It was a milestone that I celebrated that day and continue to celebrate because my periodic viral load tests still come back undetectable. 

Reaching this status was a personal demonstration in my own life of what everyone had been saying in recent years. That, thanks to ART, HIV is different now. It’s no longer the death sentence it once was but is, instead, a chronic, communicable disease that can be controlled by medication.

This is a big deal as far as I’m concerned. I’m of the generation that was most affected by the AIDS epidemic of the 1980s and early 1990s. The majority of my peers, gay guys  in the prime of their lives, were either dead or dying. At that time, there was no treatment that could have saved them. I was one of the lucky ones in that I didn’t become infected at that time, but to this day I still grieve the loss of those men - my friends, colleagues, loved ones, drinking buddies and sex partners.

Many years later, as the result of some decisions I made that I now regret, I became HIV-positive myself. But, because of the anti-HIV drugs that are now available, I’m not going to die of AIDS like my friends did 15 or 25 years ago. Rather I’m going to live the kind of active, healthy life that they could only have dreamed of. Achieving an undetectable viral load is a marker of that expectation.  

I’m fortunate in that I was diagnosed early, have access to ART and am the patient of a knowledgeable and caring physician. It was he who advised me to go on ART immediately after my diagnosis because he believes that long term outcomes are better if treatment is started early. Everything I’ve subsequently read and learned confirms that belief. On top of that, I tolerate my drugs so well that I could go from one day to another not thinking about HIV at all (except that my role as assistant editor of PositiveLite.com won’t allow me to do that!).

For many others, however, having a chronic illness such as HIV can be exhausting, unpredictable and isolating. Finding good care and treatment may be hard. And having HIV can, all too commonly, be fraught with stigma and discrimination. Meanwhile, other HIVers of my generation are long-term survivors who often suffer significant side effects and damage to their bodies caused by the toxicity of an earlier generation of anti-HIV drugs. So celebrating my own good fortune is tempered by this knowledge.  

That having been said though, having an undetectable viral load provides me with a positive sense of being in good health with good long-term health outcomes. Baring a cure, I anticipate dying with HIV, not of it.

The status of being “undetectable” also gives me a sense of positive self-esteem and emotional well-being. I’m not diseased. What I have is a well-managed, chronic illness. It’s unfortunate, but it’s nothing to be ashamed of. It’s part of the human condition.

This, in turn, has enabled me to feel good about being out of the closet, as it were, with respect to my HIV status. Proudly labelling myself, as I do, an HIV-positive gay man is a profoundly liberating experience. People can see that I’m healthy, enjoying life and contributing to the community through volunteer work (if I hadn’t reached the age of retirement, I’d still be working) and that’s allowed me to become a role model of sorts.

One of the most important outcomes for me of having an undetectable viral load is that it’s lessened the burden of worrying about infecting others when I have sex. A number of recent research studies have demonstrated that, with certain caveats, a person taking HIV treatment with an undetectable viral load in their blood should not be considered sexually infectious. Indeed, Julio Montaner, one of Canada’s and the world’s most respected HIV scientists, has publicly gone so far, in an exclusive interview with PositiveLite.com, to state that he’s “very comfortable that [ART] is at least as protective - or more - than condoms”.  

From this knowledge comes my desire to focus my energies on fighting against the criminalization of HIV non-disclosure. Because those of us who do what we have always been taught to do and wear a condom when we should or if we have an undetectable viral load - or both - don’t pose, in the words of the current law, a “significant risk” of infecting our sexual partners. What we do have, however, is a responsibility to protect our own health while not harming the health of others. That applies whether we’re HIV-positive or HIV-negative or don’t know our status. 

So, to summarize. I realize I’m privileged and don’t represent every HIVer out there, but I rejoice in my “undetectable” status. It allows me to live an active, healthy life with the expectation that, when the time comes, it’ll be old age not HIV that I’ll die of. It gives me a sense of emotional well-being that enables me to be proudly poz and to give back to the communities to which I belong. And it lessens the worry of infecting those with whom I have sex. For all these reasons, I feel blessed to have an undetectable viral load. As I said at the beginning, it’s a status that I celebrate every day.

 As we know the current anti-HIV medication, do not kill HIV but only block the replication of the virus.   However the onslaught of living with a chronic virus and the ongoing inflammation in the immune system is not easy on the body.  At infection, HIV spreads through the human body after the viral DNA of HIV is incorporated into the genome of human cells.

I do not get excited on how many new HART drugs are being churned out by the pharmaceuticals because it does the same process.  My interest lies in learning of the eradication of HIV from the human body or on the purging of contaminated HIV cells. Hence any research that looks at elimination of HIV holds my interest.  Coming down the research line is a new research published in BioMed Central’s open access journal; AIDS Research & Therapy illustrates a novel method in removing HIV in an individual by seeking out only HIV diseased cells.

Professors Abraham Loyter, Assaf Friedler and their colleagues at Hebrew University, Jerusalem, are focusing on the elimination of infected cells.  Their novel approach is to eliminate HIV in the human cells by destroying only the infected cells.  If this works out successfully, it can possibly lead to an effective anti-HIV therapy.  Loyter contends that “while HIV integrates its DNA into the human genome, it only inserts enough DNA to replicate yet avoids host genome instability leading to programmed death of the infected cells.” Programmed death of a cell is clinically referred to as  apoptosis.

While HIV is smart to prevent death of the cell which it is using to replicate millions of HIV copies, the researchers are exploring methods to cause HIV to cause cell death and if the cells dies , HIv will not be able to replicate and ultimately leads to eradication.  The researchers sought to induce increased integration of HIV DNA into human genome that could lead to programmed cell death (apoptosis).  Toward that goal, they developed peptides (called "mix") that can penetrate into infected cells and stimulate the activity of the viral integrase.  The stimulation of the viral integrase resulted in an increase in the number of the viral DNA molecules integrated into the infected cells that lead the infected cells into "panic mode", causing self-destruction.

But like any good sound research this is all preliminary research and sounds very good.  It can take awhile.  These studies are only currently effective in vitro (test –tube studies) and how it plays out in the complex human body is to be determined. Stay tuned.  ,

Ref: http://www.news-fire.com/new-approach-to-curing-hivaids-uncovered/7890/

"Immunologic response decreased with increasing age and the estimates were statistically significant.....the immunologic outcome did not differ by regimen class, but was clearly impacted by age with older individuals less likely to have an increase in of at least 100 cells/μl.....our observation that older individuals are less likely to have a robust immunologic response suggest that the optimal time to start HAART might differ by age......Our data did not show improved virologic response in older patients compared with younger age groups, as been previously shown....Previous studies concluded improved virologic response among older adults was owing to better adherence to HAART"

www.natap.org

The Coles Notes:

In the US, by 2015 over 50% of the HIV positive population will be 50 or older. Presently I do not have the stats for Canada, but the implications are obvious.

What this study is saying is that there definitely could be a role for starting your medication earlier if you are older. As the body ages the immune system, and various parts of it are not as strong, suggesting a look at individualized guideline considerations when thinking about when to start medications.

Recently at the International AIDS Conference there were new treatment guidelines out, suggesting beginning treatment earlier for everyone when their T4 count (CD4) drops below 350, and even 500.

This certainly adds fuel to the debate on when to start, and it may be older men and women becoming HIV positive may be recommended to start earlier than a 20-year-old counter part.

To read the complete abstract click here to download

Sexual risk behaviour by injecting drug users doesn’t increase once they have started HIV treatment, a study from Canada has found.

HIV treatment can both dramatically increase people’s life expectancy and reduce the chances that they will pass on the virus through sexual transmission.

But there have been some concerns that injecting drug users may have difficulty taking their treatment properly (‘adherence’), and also that people might take more risks in their sexual behaviour once they are on treatment - perhaps having more sex, more unprotected sex or a higher number of partners.

This study showed no evidence that starting HIV treatment increased any of these risk factors. The researchers recommended that different ways of encouraging and enabling injecting drug users to start HIV treatment should be put in place.

Recently I’ve subscribed to NAM – aidsmap.com. I’ve also added RSS Feeds to this site as it’s a great UK-based resource.

In today’s email update I received an update. I suggest others to sign up as it’s a great bit of chunked easy to understand information.

Today’s update included something that caught my eye, and it wasn’t the fact that the study is from Canada.

My commentary is that it’s great news, and not surprising that HIV treatment can be extremely beneficial to those who take it. There was also one other little piece of good news, however I feel the need to editorialize about the context of what I’m reading.

There has been a long history of neglect and criminalization of those who have drug dependencies instead of looking at it as a health issue. Just look at our Harper government who’s gone to great lengths to fabricate research against Vancouver’s safe injection site, “Insite” In Russia, there is no such thing as methadone treatment, just lock them up.

When it comes to drug users, we (society, research community, government) seem to see them as some sort of child-like human species that can only be treated in a paternalistic manner while always judging them as bad.

“Concerns” about adherence yes can be difficult, it can be difficult for a lot of people. The goal should be to develop systems that we can help them take their meds in the best way, but should never be a reason to deny or delay treatment.

Secondly, the judgment that if drug users are giving HAART they are going to go out and have all this irresponsible unsafe sex – almost by the tone of this study, encourage them as in the same way right-wing folks think sex education is going to make your daughter go out and have a threesome next Saturday night. We don't study this kind of "concern" among women, gay men, and people of various ethnicities.

I’m a little shocked that this concern was expressed and studied. Should that not mean that “anyone” receiving HAART therapy may be prone to going out and having unsafe sex. To me this is bizarre.

It appears the raison d’être for the study is really about stopping transmission, once again highlighting the new front of debate “health public policy vs. private rights.” Are we moving in a direction where we are only thinking about the broad benefit of treatment and not about individuals health.

Reducing transmission should be a side-benefit of treating those who need therapy, and are provided a process where informed consent can be obtained. Moreover, we need to start looking at addicts with very serious health and psychological issues who need help, instead of a sub-set of the human race that is highly stigmatized. Even in the tone this report there is language makes me feel really uncomfortable.

Ultimately my concern for drug users is that they have access to the services they need, including rehab, medical care etc. That they have the right for non-biased care by physicians and that systems are developped to work best for them and their needs with the ultimate goal of getting out of the cycle of drug use - poverty - and the sex trade industry.

And that’s my two cents as someone who's been there.