HIV, or human immunodeficiency virus, is a virus that attacks certain immune cells in the body known as CD4 T-cells and macrophages. CD4 T-cells and macrophages are found in the blood, lymph nodes, and in the tissues lining the rectum, the urethra, and the under-side of the foreskin. These cells form an essential part of your immune system and help fight off infections. When HIV enters the body it infects CD4 T-cells and macrophages and lives inside these cells. The virus is harmful to the cell, making it difficult for infected CD4 T-cells and macrophages to carry out their normal immune functions. Slowly, the infected cells become increasingly sick and non-functional, and eventually die. As this occurs, the immune system becomes weaker and weaker. Eventually, the immune system becomes so weak other viruses and bacteria area able to attack the body. When this happens, it is called AIDS. Fortunately, there are medications that can prevent HIV from harming the cells it infects, and so keep the immune system healthy and functional. These days, AIDS is relatively rare in Canada.
Because HIV is a virus it can’t survive for very long outside the body. For this reason, HIV is only transmitted from person to person through certain bodily fluids. For us gay guys, these fluids are blood, cum, pre-cum, and rectal fluids. HIV is not transmitted by just touching one of these fluids from an HIV+ person. The fluids have to actually enter your body through a cut in your skin or through a mucous membrane, a thin layer of skin such as the lining of your rectum, urethra, or the underside of your foreskin. Because of this, sex and sharing needles are the most common routes of transmission. If you bottom without a condom, the thin lining of your rectum may be exposed to pre-cum or cum. If there is HIV in the pre-cum or cum, it will then have easy access to and be able to infect the CD4 T-cells and macrophages located just under the lining of the rectum. If you top without a condom, the lining of the urethra and the underside of the foreskin will be exposed to rectal fluid. If there is HIV in the rectal fluid, it will be able to infect the immune cells just under the lining of the urethra or inner foreskin. If you are circumcised, that is you don’t have a foreskin, the risk will be lower when you top although transmission through the urethra can still occur. Activities such as hugging, touching, and kissing do not transmit HIV.
Anyone can become infected with HIV, but gay men are at greater risk, accounting for almost 50% of new infections each year in Canada. This does not mean that as a gay guy you will get HIV. But it does mean when you hook up, whether you are positive or negative, you may want to take some steps to reduce the chances of HIV transmission. Today there are a number of options and strategies, so pick the ones that work for you and your partners. Condoms remain one of our best prevention methods as they reduce the chances of transmitting HIV as well as a number of other sexually transmitted infections like gonorrhea and Chlamydia. If you are HIV+, taking antiretroviral medications and maintaining an undetectable viral load will greatly reduce the chances of passing on HIV. In fact, research now indicates that HIV+ guys with an undetectable viral load don’t pass on HIV to their sexual partners. For negative guys, PEP and PrEP involve taking antiretroviral medications to help protect them from getting HIV. You can read more about these in HUGO’s HIV Prevention section. For many guys, HIV is like a monkey on our back when we have sex. Poz guys worry about potentially passing on HIV, and negative guys are afraid of getting HIV. As a result, for many guys, sex can provoke a great deal of anxiety. Taking steps to reduce HIV transmission, whether it is condoms, PrEP if you are negative, or being undetectable if you are positive, can reduce anxiety and make sex less stressful. Regardless of whether you or your partner are positive or negative, sex should be fun, pleasurable, and satisfying.
Generally, HIV does not have symptoms, so people may have HIV and not know it. Sometimes when people are newly infected with HIV they experience flu-like symptoms, such as fever or chills, a sore throat, swollen lymph nodes, or diarrhea. This usually happens around four to six weeks after infection. Not everyone develops these symptoms though, or they may be very mild. Once the HIV infection is established in the body, people can feel well and remain asymptomatic for years. This may lead people to believe they don’t need to be tested or treated. Without treatment though, HIV will slowly destroy the immune system. Eventually, without medications to control HIV, the immune system will be so weak other viruses and bacteria can attack the body. At this point, symptoms from these infections will develop. Individuals who are not treated for their HIV may develop, for example, severe shortness of breath due to pneumocystis pneumonia.
HIV is diagnosed through a blood test, either by pricking your finger and taking a few drops of blood, or by taking a vial of blood from a vein. Testing by pricking your finger is called a rapid test or Point-of-Care test, and provides results within a few minutes. If the test is negative, you do not have HIV. If the test is positive, your doctor or nurse will take a vial of blood from your vein to do a confirmatory test. The rapid test does not provide an HIV diagnosis. When blood is drawn from a vein, it is sent to a lab where both screening and confirmatory tests are done. Results though can take up to a week. The rapid test does not detect the HIV virus itself, but looks for antibodies your body makes to HIV if it is present. Because it takes time for your body to make these antibodies there is a period lasting up to 12 weeks during which HIV may be present, but the test is negative. This is called the “window period”. The laboratory test done with a vial of blood is more sensitive and looks for both HIV proteins and the antibodies you make to the virus. Because of this, the window period is much shorter for the laboratory test at about 42 days.
While there is currently no cure for HIV, treatment today allows HIV+ individuals to lead perfectly healthy lives. The medications used to treat HIV are called antiretrovirals, they are taken in combinations, usually three at once, but can sometimes be only two. This is referred to as antiretroviral therapy. (In the past, these drugs were often referred to as HAART or “the cocktail”. These terms are no longer used.) Today, many single pill combinations exist. These pills contain two or three antiretroviral medications combined into one tablet.
If you have HIV your doctor will do blood tests to monitor two things in particular, your CD4 count and your HIV viral load. The CD4 count shows how well your immune system is functioning. HIV infects CD4 T-cells and slowly kills them. As these cells decline in number, the immune system becomes weaker. No one ever gets their CD4 count measured before they contract HIV, so it is hard to know where they started. But in general, most healthy people have more than 500 CD4 T-cells in a microliter of blood (one 50th of a drop). With that said, we know from years of experience if you have more than 200 CD4 T-cells per microliter of blood, your immune system will be able to function adequately. The other important blood test is the HIV viral load. This measures how much virus is present in a milliliter of blood (20 drops). When people with HIV do not take antiretroviral medications the virus replicates out of control and the amount of virus present in the blood can range from a thousand to hundreds of thousands of viruses per milliliter. This leaves the immune system under constant attack. Antiretroviral medications are very effective at shutting down the virus. They prevent HIV from replicating and keep it inactive. If the virus is inactive it cannot harm your immune system. When HIV is “locked down” by antiretroviral medications, the amount of virus in the blood becomes so low it can no longer be detected. This is what it means to have an undetectable viral load, or to be “undetectable.” Individuals who have HIV, but maintain an undetectable viral load, have healthy immune systems that function normally. They are at no greater risk of getting sick than someone who does not have HIV. To keep the viral load undetectable though, the antiretroviral medications must be present in the blood at all times. It is essential then to take the medications every day exactly as prescribed. If the antiretrovirals are stopped, HIV will reactivate and not only renew its attack on the immune system, but potentially mutate and become resistant to the medication.
When it comes to antiretroviral medications, many people worry about side effects. Unfortunately, these medications have a bad legacy. Back in the 1980’s and early 1990’s, when HIV first exploded on the scene, there was a push to find drugs to treat the virus and make them available as quickly as possible. As a result, the early drugs were rather crude with significant toxicities. Today, 30 years later, the antiretroviral medications used to treat HIV are far better and more refined. They are extremely effective at controlling HIV and most have few if any side effects. Of course, anyone can have an unexpected reaction to any drug, even penicillin, but for most people the newer antiretrovirals are easy to tolerate. If you have HIV and are starting antiretroviral medications, discuss the potential side effects with your doctor and pharmacist, and let them know if you experience anything unexpected. Be wary though of what you read on-line. Many websites have not updated their information.