Stressed about superinfection
*Rob, from Ascot Vale Vic, writes*: I have recently started a relationship with another positive guy who is not taking any treatments. I have been taking antivirals for six years and have tried three different combinations as I have had some drug resistance. My partner has never taken HIV drugs and I am concerned about the possibility of transmitting resistant strains of the virus to him.
A number of my positive friends say I shouldn’t worry, that the chance of passing on HIV resistance is unproven, but recently I read some research on the internet which said that it was a bigger risk if your partner had never taken any treatments before. At the moment we are having protected sex but my partner really doesn’t want to use condoms — that was one of the reasons he wanted to find a positive partner. I will need a convincing argument to tell him otherwise!
Dr Nick Replies: It is not possible to give concrete advice on this question, as the evidence is very scanty. We do know that it’s possible for a positive person to infect their partner with a drug resistant strain of HIV that might cause them to fail their antiviral therapy — a small number of cases of this have been reported. What we don’t know is how easy it is to do that, what circumstances might make it more or less likely, or how often it occurs. It may be that this is a very common occurrence, and that the risk to your partner is high, because this ‘epidemic within an epidemic’ would probably pass unnoticed. However, it may be that this is a rare event and hardly ever happens. We just don’t know.
The other concern is that one partner might be infected with a more virulent strain of HIV, or that over the years the virus in that person may have become more virulent. This situation might be of concern when the partners are at very different stages of HIV infection — one with advanced HIV infection, high viral loads and low CD4 counts and the other very early on.
The lowest risk situations are probably when both partners are not on any treatment at all (so the virus circulating is garden variety HIV common in Australia) or when the partner on treatment has had undetectable viral load for some time (in which case there is very little HIV circulating).
That is, neither partner on treatment, both partners with undetectable viral load or one partner not on treatment and other partner with undetectable viral load.
But this answer is entirely speculative, based on very little data. Until it is studied in depth, we cannot be certain of the real risk.
Chlamydia the Culprit?
*Brenton, from Strawberry Hills NSW, writes*: I’ve recently become HIV-positive. It was a big shock for me because I have only ever been the active partner in sex and I have not had very much unprotected sex at all. A sex partner who I have occasionally had unprotected sex with (before I became positive) told me that he had picked up chlamydia.
I was wondering if chlamydia might have increased my chances of picking up HIV from this partner? I have inserted sometimes without a condom but I never came inside him or inserted for very long. I know you can get HIV from being a top but would this have increased my chances?
Dr Nick replies: The answer to your question is YES: chlamydia increases the chances of transmitting HIV. So do gonorrhoea, syphilis and herpes, and rates of sexually transmitted infections (STIs) are skyrocketing among gay men in Australia.
The interactions between STIs and HIV transmission work both ways.
If a positive person has an STI then they are much more likely to pass on HIV to their partner, because STIs cause inflammation, making body fluids and natural mucus very rich sources of HIV. Anal chlamydia, for example, causes irritation and inflammation of the anal canal, meaning that if someone had anal sex with that person then there would be much more HIV in the anus. In one study as many as one in ten sexually active gay men were carrying this bug.
If a negative person has an STI, their chances of picking up HIV are also much increased, for the same reason. Inflammation of the vagina, anal canal, or the inside of the eye of the penis (as occurs in gonorrhoea and chlamydia), or a small inflamed sore on the penis, vagina or anus (as occurs in syphilis and herpes) make it much easier for the virus to get into their system and infect them.
There is little doubt that we are in a state of emergency with these interactions. The last time that we had the combination of high rates of unprotected sex and rising STIs was in the early 1980s, when HIV ripped through the gay communities in Australia. It’s hardly any surprise that HIV is rising again. There’s no real reason to believe at this point that it won’t be as widespread as it was then.
Unfortunately there’s no way of being sure if you are your partner have HIV or an STI without getting tested. Being a top is marginally less risky than being a bottom, however, when a good proportion of people are infected with anal chlamydia, the relative risk reduction of being a top almost certainly disappears.
Needled by Neuropathy
*Steve, from Ivanhoe Vic, writes*: I have been getting a lot of pain in my feet of late. It is particularly in the ball of the foot and is only alleviated by putting my feet up. It is quite an intense ache and it seems to be getting more intense and constant. I am wondering if I could be developing peripheral neuropathy. I am not sure what the symptoms are — can you explain them to me? I am on d4T, 3TC, Kaletra and tenofovir. I have been treating for about eight years now and have known I was HIV positive since 1987. Are there simple things that can help if it is neuropathy?
Dr Nick replies: The symptoms you describe could well be peripheral neuropathy (PN) and, as this is a known side effect of d4T, I would strongly advise you to see your doctor about it.
PN causes numbness, burning or aching in the soles of the feet, slowly spreading upward. Someone people get a dead or wooden sense from their feet. It sounds like your peripheral neuropathy is getting worse — you should discuss with your doctor if it’s possible for you to be on a different antiviral combination. Don’t just stop, but ask if it’s possible to swap it for another. You’ll probably need to change more than just the d4T — it is never safe to just stop one drug as this can cause drug resistance.
Until recently we didn’t realise how common PN is. We also had fewer antivirals and for some time we operated on the mistaken belief that d4T was not toxic. As a result we’ve seen an enormous amount of peripheral neuropathy. These days it should be possible to avoid PN, by using drugs that don’t cause it.
If you change your combination you might notice the PN continue to get worse for a few weeks to a couple of months (a phenomenon called ‘coasting’). Eventually, though, the intensity of the burning should start to subside. Some of the numbness might remain, depending on how severe the PN has become.
Other than removing the cause, some preliminary studies of acetyl L-carnitine, an antioxidant, showed promise in reducing the damage to nerves. Low doses of the antidepressant amitriptyline can reduce the symptoms in some people, and acupuncture, irritant creams and applications like deep heat, or even nasal decongestant drops, provide some relief for some people.
