Finally, we’re going to talk a little bit about prevention,
and obviously the gold standard would have to be abstinence.
Many espouse the idea of safe sex,
and of course, that includes the use of condoms,
which had definitely been shown to reduce the transmission of HIV
and other sexually transmitted infections.
Antiretroviral therapy is part of the prevention
because an infected patient has less virus in the bloodstream
and less virus in genital secretions
so they are less contagious.
There is debate about whether we should be giving
antiretroviral therapy to patients before they're infected.
There are studies which definitely document that it works,
but you can see how it might be controversial
just because somebody’s in a risk group to give them antiretroviral treatment.
The same thing can be argued about post-exposure prophylaxis.
A person might have had sex with someone – should they get an antiretroviral agent?
There are data to document that, that does work.
Certainly, we need to treat other sexually transmitted diseases
because having another sexually transmitted disease
makes someone more likely to pick up HIV infection
if they did not already have it.
And then obviously for the innocent victims,
we need adequate prenatal care and perinatal care
to protect not only the mother, who might not even know that she’s infected,
but the baby.
And another controversial topic is that of male circumcision.
It is clear that uncircumcised men
have a slightly higher incidence of developing HIV infection.
Whether you should recommend circumcision to an adult male
is certainly somewhat controversial.
Now as far as occupational exposure,
for us who are in the medical profession and other healthcare workers,
we need to obviously avoid needle stick injury.
And so, caution is certainly advisable
in dealing with the infected secretions and blood of HIV infected persons.
But let’s say you get stuck.
What is your risk of HIV infection from a needle stick?
It’s about 1 in 300, so it’s not a very high risk.
And I might add this --
it makes me think about the physicians of the early 1900s and the late 1800s
who took care of patients with tuberculosis
and knew they would likely come down with TB.
To me, brothers and sisters, that’s what being a doctor is all about.
So if you are afraid to deal with patients
because you might become infected yourself,
I think you need to ask yourself whether you’re in the right profession.
But the risk is low. So in terms of preventing –
should you get a needle stick or some kind of other injury
exposing yourself to blood products –
there is a way to reduce the risk further using antiretroviral drugs.
And what’s recommended currently is Raltegravir,
which is an integrase strand transfer inhibitor,
plus tenofovir-emtricitabine in combination.
These are nucleoside reverse transcriptase inhibitors
and taking these drugs for 4 weeks.
It wouldn’t be fun because there have side effects,
but they are very effective in preventing HIV infection following a needle stick injury.
Now, what about pregnancy and HIV infection?
If a patient has never received antiretroviral therapy,
then antiretroviral therapy should be considered upon the diagnosis of HIV infection
in a pregnant woman.
And what’s recommended is atazanavir, protease inhibitor,
plus 2 nucleoside reverse transcriptase inhibitors,
and these are safe to both mother and baby.
And the transmission risk to the infant is 0.09 percent
if the viral load is less than 50 copies per ml,
so this prevents infection of the baby essentially.
So I think it’s important to show you the effect of therapy on HIV infection.
Untreated, it is still a death sentence.
And I think you can see from this graph that you start out with primary infection.
And the CD4 count drops drastically, and then bumps up for a few weeks to months.
And then, over a period of several years,
the CD4 count in an untreated individual drops to nothing essentially
that’s compatible with an effective immune system.
Meanwhile, the viral load rises dramatically.
And then with the response of the immune system begins to drop down
only to gradually rise to very high counts at the point of death.
So it is a death sentence untreated.
But the hopeful part is that, among patients who have access to care –
and I’m not saying that's perfect –
but among those patients who have access to care,
the life expectancy of someone who’s HIV infected
and religiously takes their medication and goes to follow-up visits
is only 9 years shorter than an HIV-uninfected person.
And decreasing the risk factors among HIV-infected persons
may decrease this disparity.
And that concludes my discussion of HIV infection for you
and I hope it has helped.