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By Jerry Thacker
My wife was infected with HIV through a blood transfusion she received in 1984 after she gave birth to our daughter via C-section. She passed the virus on to me and through breastfeeding communicated it to our daughter. We didn't find out about our infection until two years later.
 In the early 1990s, I published the book When AIDS Comes Home under a pen name. In that book I suggested that people wanting to contact us (we weren't public about our infection then) should call our publisher and leave their information. The first reply was from an HIV-serodiscordant couple (only one spouse is infected with HIV).
The only completely effective means of not communicating HIV from the infected partner to the uninfected partner has been total abstinence—avoiding all sexual contact. While for some couples this has been an effective means of countering the risk, for many others, their desire to participate in sexual activity with each other has made it difficult to avoid the risk.
How do you counsel a couple that comes into your pregnancy care center when you find out one is HIV infected and the other is not? What is the risk of the infected person's transmitting HIV to the uninfected partner with each sexual contact they have? What is the impact of HAART (Highly Active Anti-Retroviral Treatment) on the reduction of virus in bodily fluids and the possible transmission of HIV through sexual activity? Let's take a look at some of the current information.
Regular blood tests are performed to monitor two factors in HIV patients: the CD-4 T-cell count and the viral load.
How do you
counsel a couple
when one is
HIV infected
and the other
is not?
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The CD-4 T-cell count indicates the health of the person's immune system. The normal range is 800 to 1,200 CD-4 T-cells per milliliter. Someone with a measurement of 500 or less is said to be "immune compromised." Someone with less than 200 CD-4 T-cells and with some sort of opportunistic infection in tow is said to have "full-blown AIDS."
Viral load is a measure of viruses per milliliter of blood. In an uninfected person, this number would be zero as ascertained by polymerase chain reaction RNA testing. A person who is HIV infected will start to show a viral load that increases from the time that the virus infects the body until the person eventually succumbs to opportunistic infections. People who have viral loads of less than 50,000 are usually not treated with HAART therapy unless their T-cells are extremely low.
The current wisdom is that when the T-cell count is between 278-300 and the viral load is above 50,000, treatment options should be discussed with a physician. In many cases, when HAART therapy is started, the patient's immune system recovers and his T-cell count goes up. Also, his viral load goes down, and if it reaches a level of less than 400 to 500 copies per milliliter of blood, it is usually labeled "undetectable" by the current testing method.
Recent studies have shown that not only does the viral load in the bloodstream go up as HIV progresses, but it also goes up in other bodily fluids such as male and female sexual fluids. In reality, the person's ability to infect someone else is directly proportional to the viral load found in various bodily fluids.
LESSONS FROM UGANDA
Several years ago, I had the opportunity to be in Uganda. The HIV rate among the general population in Uganda has decreased dramatically through a primary emphasis on abstinence; however, there are other findings from Uganda that are also quite interesting. In the Rakai district, a study was done of 15,000 men and women ages 15 to 59. At follow-up visits every ten months, participants were asked to provide blood and urine samples and the women were asked to contribute a self-collected vaginal swab. All of these fluids were tested for HIV. An interview of the sexual characteristics and behaviors of the couple was also taken. This study appeared in the Journal of the American Medical Association. Keep in mind that HAART therapy drugs are not readily available in Uganda as they are in the United States; therefore, the study reflects the natural path of HIV and the transmission from one individual to the other without any intervention from modern drugs. The findings of the study show that people with a viral load of less than 1,500 copies per milliliter seemed never to transmit HIV to their partners; however, as viral loads increased, HIV was passed on through sexual relations. The lesson here seems to be that keeping the viral load to low or undetectable levels is the key to keeping an uninfected partner healthy.
"The viral load of an HIV-positive partner is the most important factor affecting heterosexual transmission of the virus in rural Uganda."1 "Among 415 serodiscordant couples identified in a population-based study in Rakai, transmission rates increased with the number of copies of HIV ribonucleic acid (RNA) in the blood, from two seroconversions per 100 person-years when the infected partner had fewer than 3,500 copies per milliliter to 23 per 100 person-years when the partner had at least 50,000 copies per milliliter. No seroconversions occurred when the HIV-positive partner's viral load was less than 1,500 copies per milliliter."2
CONDOM EFFECTIVENESS
One of the most frequently asked questions is: What is the effectiveness of condoms in preventing HIV transmission? The simple answer is that they are somewhat effective. Studies show that the probability of HIV transmission when the infected partner's viral load is above 1,500 is between 11 and 20 percent during any twelve-month period, even with the use of a condom. Total compliance to a working HAART program that keeps viral load to undetectable levels would decrease the risk according to the Ugandan study.
There is a strong
likelihood that
your center will
encounter an
HIV-serodiscordant
couple.
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THE BOTTOM LINE
When counseling an HIV-serodiscordant couple, the first thing you need to tell them is that HIV still has no cure. This disease will eventually result in death for the person who has it. Recent advances in medical intervention in the United States have almost rendered HIV chronic and manageable; however, there are still many side effects to the drugs that are used in the HAART therapy, and strict compliance with the dosing regimen is essential in order to maintain viral load reduction. Secondly, serodiscordant couples need to be counseled that there will always be some degree of risk attached with sexual activity and HIV. Condom failure, missed medicines, illness, and many other factors may increase the risk of obtaining HIV from an infected sexual partner. It is up to each couple to decide if that risk is at an acceptable level for both of them before they proceed with sexual activity.
I believe that true love never puts the object of that love at an unnecessary risk. However, the future for serodiscordant couples is brighter than it has been in a long time. Currently, they are able to, in many cases, have children, enjoy each other's company, and have a certain level of sexual contact. Everyone who has access to the HAART drugs is living a longer life than ever before possible with HIV infection.
The wise CPC/PCC counselor will educate the HIV-serodiscordant couple just the same as they would regarding the options of abortion and adoption or carrying a baby to term. The counselor should also stress to the HIV-serodiscordant couple the need for fidelity and inform those who are HIV negative that the possibility of getting HIV increases proportionally with the number of sexual contacts.
With roughly 800 to 1,000 people in the U.S. becoming infected with HIV each week, there is a strong likelihood that your center will encounter an HIV-serodiscordant couple. The medical landscape for the HIV-serodiscordant couple is constantly changing as new treatments provide more effective means of keeping the virus under control. The serodiscordant couple will need to have the most up-to-date information in order to best understand their options and make wise decisions.
| Jerry Thacker is Founder and President of Scepter Institute. To learn more, see Scepter's site at www.scepter.org. |
1 Quinn, T.C., et al., "Viral load and heterosexual transmission of human immunodeficiency virus type 1," New England Journal of Medicine, 2000, 342(13):921-929.
2 International Family Planning Perspectives Volume 26, Number 4, December 2000, www.agi-usa/pubs/journals/2620300a.html.
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