Merck Manual

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A Message in Honor of World AIDS Day— "Know Your Status"

Commentary
11/25/2019 Edward R. Cachay , MD, MAS, University of California, San Diego

Sunday, Dec. 1 marks the 31st annual World AIDS Day. Each year, the day offers people around the world a chance to unite in the fight against HIV, show support for those living with HIV and to commemorate those who have died from AIDS-related illnesses. In honor of this important day of recognition, the Merck Manuals editorial team sat down with Edward Cachay, MD, to discuss the importance of awareness and how perceptions surrounding the condition in the United States have changed over the years. Dr. Cachay is an infectious disease specialist and professor of medicine at the University of California, San Diego, and author of the Merck Manuals chapters on Human Immunodeficiency Virus (HIV).

Are there fewer cases of AIDS today than there have been in the past?

Dr. Cachay: Proportionally, the short answer is yes. In 2016, the number of HIV cases decreased to under 39,000, according to the Centers for Disease Control. But just as importantly, the number of AIDS cases continues to decrease. This decrease in the life-threatening progression of the condition reflects two important things. The first is the impact of public health efforts in generating awareness and effectively screening populations at risk. And second is the emergence of better and highly effective immunotherapy and tools to treat HIV infection.

What is the difference between HIV and AIDS?

Dr. Cachay: HIV (human immunodeficiency virus) is a virus, as the name implies. It’s transmitted from one person to another through the exchange of bodily fluids. AIDS (acquired immunodeficiency syndrome) is a condition a person acquires only after they’ve contracted HIV. The simplest way to think of it is that a person can be infected with HIV for a long time, but if the condition is unrecognized or untreated, then they can develop multiple complications that define AIDS.

How have people’s perceptions of HIV and AIDS changed since you started practicing?

Dr. Cachay: Twenty years ago, AIDS was a death sentence. There was no effective treatment or cure. Today, in many cases, it is a condition that can be managed quite well with proper medical care and treatment. This treatment has improved dramatically from 20 years ago, but AIDS has not gone away completely yet.

Is AIDS less deadly today? Is there a cure?

Dr. Cachay: Doctors today can better recognize and precisely stage the multiple complications associated when a person develops AIDS, and we have much more experience in how to treat AIDS-related complications. New technology and new therapies increase the odds of survival when someone is diagnosed with AIDS.

But right now, there is no specific cure for HIV. There are multiple areas of research, and we are actively looking for a cure. Our aim with current therapies is to boost the immune system, so the individual is out of the threshold for AIDS and avoids potential complications and ideally has a long, good, and productive life.

Are more people getting tested for HIV?

Dr. Cachay: Absolutely. More and more people are getting tested, and there’s been a successful effort to diversify screening locations outside of clinics and hospitals. Screening is being done in places like community centers, mobile units, and other venues, and groups are using social media to get the word out so more people can get tested.

What are the main risk factors for HIV infection today?

Dr. Cachay: To answer this question, it’s important to first recognize how HIV gets passed from one person to another. That is through blood, through intimate fluid during sex, and through breast milk. The number one cause of HIV transmission in the US is condomless sexual activity. Choice of partners also plays a role. Having sex with individuals who use illegal drugs or who are commercial sex workers increases the chances of contracting HIV. Other risk factors include sharing needles and, unfortunately, mother-to-child transmission.

Given those risk factors, there are also a few facilitators that can make transmission more likely. The first is alcohol and recreational drug use, which can weaken people’s judgment and make them more likely to engage in risky behavior like unprotected sex. The other risk facilitator is intimacy with someone with a concurrent sexually transmitted infection such as herpes, syphilis, chlamydia, or gonorrhea, which can cause changes to the tissue of the penis or the vagina that makes it easier for HIV to be transmitted during sex.

How can people prevent HIV infection?

Dr. Cachay: From a public health and community perspective, we need to scale up campaigns that increase awareness about HIV and address the stigma around HIV so that more people get tested. We should remind people that HIV can affect anyone in our communities, not just high-risk groups. People with HIV are mothers, fathers, friends, brothers, sisters, coworkers, husbands and wives. We are all part of this community and we are all at risk. It’s OK to talk about the importance of testing and awareness.

On an individual level, the best thing people can do is to use condoms during sex. For people with a high risk of being infected, taking an antiretroviral drug before being exposed to HIV can reduce the risk of HIV infection. Such preventive treatment is called preexposure prophylaxis (PrEP). Another important component is harm reduction for intravenous drug use by doing things like needle exchange programs and opioid substitution therapy.

How important is education in addressing the stigma?

Dr. Cachay: Education is paramount. We often assume people learn about HIV at school. But it’s the conversations that happen at home that can have a big impact on addressing the stigma and educating people about potential risk factors. We need to be having pragmatic conversations, especially with young people, about things like safe sex and the risks of sharing needles and drug use. That education is so critical to HIV prevention efforts.

Who should get tested for HIV?

Dr. Cachay: Ideally, everyone in the community should be tested. The formal recommendation since 2006 is that everyone aged 13 to 65 should be tested at least once. Individuals at higher risk of HIV infection should be tested more often. Men who have sex with men should be screened annually when they are not taking PrEP. Men who have sex with men taking PrEP should be tested every three months. Pregnant women should be tested during each pregnancy. People who inject drugs should be tested at least annually, but perhaps more depending on specific circumstances.

What is the number one thing you want people to know about HIV?

Dr. Cachay: Know your HIV status. This is critical to prevention as well as disease management. If someone is not infected with HIV, actions can be taken to prevent HIV acquisition, such as receiving PreP. If someone is infected, they can receive treatment to reduce the risk of passing it to someone else. What’s more, someone who knows their status can receive treatment that allows them to live a long, productive life.

Here’s one more recommendation which I often share with young people. Love and be loved. That’s your right. But make sure that your love is always sober and protected.

Edward Cachay, MD

Test your knowledge

Hyper-IgM Syndrome
Immunodeficiency disorders are disorders that interfere with the body’s ability to protect itself against infection. The body defends itself by producing substances called immunoglobulins. Hyper-IgM syndrome is a primary immunodeficiency disorder involving normal or high levels of immunoglobulin M (IgM) and decreased levels or absence of other immunoglobulins, making patients prone to bacterial infections. Most cases are linked to a mutation in a gene on the X (sex) chromosome. Which of the following groups is most likely to have this condition?