The Ins and Outs of Gay Sex (18 page)

A
young man, still in his twenties, sits before me.
We’re separated by my desk, but he seems miles away.
He shifts in his chair, and his smile droops at the corners.
I’ve been taking care of him for close to a decade.
I thumb through his records—eight tests and all negative.
I can’t stall any longer, so I take a deep breath and shatter his world.

“This time your test was positive.”
There, I’ve said it.

His smile stays frozen, and only his watery eyes tell me he’s heard.
I point to the box of tissues, but he shakes his head.

“I’ve kind of been expecting it,” he says finally.
“I mean, it was just a matter of time.”

He’s so wrong.

In 1981 growing numbers of gay men arrived at emergency rooms in New York and California with
Pneumocystis carinii
pneumonia (PCP), a disease doctors rarely saw.
Whether called gay-related immune deficiency (GRID) or by any of the other early names attached to it, AIDS had arrived.
Although it wasn’t until 1983 that the human immunodeficiency virus (HIV) was finally identified, scientific evidence points to its presence in this country as early as 1978.
In 1985 the Food and Drug Administration licensed the first test to detect HIV, but it wasn’t until 1987 that zidovudine (AZT, or Retrovir) became the first drug approved specifically for AIDS treatment.
Until then available medications treated only the infections and cancers that HIV allowed to proliferate.
So many milestones in a disease not even identified twenty years ago, but for most it has seemed like a lifetime.

The World Health Organization (WHO) estimates that, worldwide, over 30 million people had HIV at the end of 1997 and, if trends continue, by the new millennium, 60 to 70 million adults will carry HIV, with 90 percent of them living in Third World countries.
Already in some African countries 25 percent of adults carry the virus.
To date, more than 60 percent of those with HIV have died.
In the United States, over 600,000 cases of AIDS have been reported to the Centers for Disease Control, and more than 50 percent of these infections occurred in men who have had sex with men.
This number, however, is falling while rates for heterosexual transmission are rising.
The Centers for Disease Control estimates that more than 40,000 to 80,000 new HIV infections occur in the United States each year.
Most recent data give New York City the dubious distinction of having the most cases of AIDS, with Los Angeles coming in second.
Even with all we have learned over the years about safe-sex practices and the advent of new drugs, HIV is still prevalent and deadly.

This chapter is an overview of HIV, its treatment and prospects for the future.
It is not a substitute for a conversation with your doctor.
Although the information presented is current, HIV treatment changes almost daily.
What you read today may not hold true several months from now.
Because of the rapid advances in the field, I urge you to be tested regularly—especially if your sexual practices place
you at risk—and see a physician the moment you test positive.
HIV is not something that will go away if you ignore it.

The key to living a long and healthy life depends as much on your efforts as on medications.
Find a doctor whose practice is largely devoted to HIV, because treatment is complicated and should not be left to someone who sees only a few cases each year.
Those of us who treat AIDS still see patients ravaged by disease begging for help.
They come to us as a last hope, after years of being treated by some doctor watching viral loads rise and T-cells fall while telling them there is no real treatment for this virus.
While there is no specific medical specialty in AIDS treatment, most physicians working in the field are internal medicine specialists with a special interest in the disease.
(See
Chapter 12
.
)

When I tell most patients they have HIV, their eyes close as they recall “that time” they messed up.
Most want to talk about it, as if admission lessens their guilt.
They speak in half-thoughts of memories suddenly too painful to bear.
This young man was no different.
He bit his lower lip and shook his head while I waited for him to speak.
“He’d only rub it on the outside.
He promised … but then it was on the inside—it felt too good.
I tried to say something, but his kisses swallowed my words.”

“You were too afraid he’d leave,” I said.

His eyes widened as if he suddenly understood.
“He promised he wouldn’t come.”

The guy lied.

Every HIV-positive man has an excuse why he let down his guard.
After years of preaching the importance of safe sex, gay men still contract the virus.
Perhaps it was the Ecstacy or alcohol that made you drop your guard.
Or maybe you’re just sick of those condoms.
Many men allow unprotected
sex because they’re too afraid they’ll lose the hottest guy they’ve ever had if they ask him to put on a condom.
I am always angered when someone tells me that safe sex is such a “bother” and doesn’t really matter—now that the protease inhibitors practically cure the disease.
Sadly, this is not the case.

There are two types of human immunodeficiency viruses:
HIV-1 and HIV-2.
HIV-1 causes most of the cases of AIDS in the United States, with only isolated HIV-2 infections reported.
The virus is a retrovirus and contains RNA instead of DNA as its genetic code.
For infection to occur, the virus must get into your bloodstream and bind to a protein receptor on your lymphocyte.
(It’s like a little landing pad.
) But it cannot infect just any lymphocyte.
HIV specifically targets CD4+ lymphocytes, which are a type of T-cell.
Once firmly attached to the T-cell, the virus injects its RNA into the cell.
In humans, our genetic building block is DNA, not RNA.
An enzyme called reverse transcriptase converts HIV RNA into DNA.
This newly formed virus DNA passes into your cell’s nucleus and links up with your own DNA.
Then viral DNA commandeers its host’s reproductive machinery, issuing a command to manufacture more copies of virus DNA.
At this point your CD4+ lymphocyte has been converted into an HIV factory.
Besides manufacturing viral DNA that gets changed back into RNA, your lymphocyte also builds protein coats to cover the HIV RNA.
After each new virus is fully assembled, it leaves the CD4+ cell to infect other T-cells.

Sound complicated?
For sure, but it is also a highly efficient process producing an estimated 10 billion copies of HIV each day.
Medications combat HIV by blocking any number of these steps in reproduction.
Most HIV does not
circulate in your bloodstream; instead it remains hidden in T-lymphocytes and lymph nodes.

Your immune system fights back by manufacturing antibodies that attack the HIV, but they can’t wipe out the infection.
Most HIV tests measure these antibodies.
A positive test indicates infection.
In three weeks to six months antibodies appear and virus levels in your blood fall.
The disease then enters its clinically “latent” phase when most men feel fine, but their CD4+ lymphocytes are gradually being destroyed.
After approximately ten years without treatment, CD4+ counts fall below 200.
With increasing suppression of your immune system, HIV proliferates and your viral load (a measure of virus particles in your bloodstream) rises.
It is at this point that AIDS develops.

HIV is not that easy to catch.
The virus spreads through blood or bodily fluids (semen and possibly saliva).
Gay men are infected most often through unprotected anal sex (ejaculation is not required) or intravenous drug use with shared needles.
You may be thinking that you’ve never shot drugs, but how about steroids?
Ever share a needle for that?
The virus doesn’t care if it gets into your body on a coke, heroin, or steroid ride.

Although some researchers report isolated cases of HIV transmission through oral sex, the risk is far lower.
(See
Chapter 9
.
) Open cuts on fingers or in your mouth or anus make infection more likely.
Concomitant STDs, including herpes and gonorrhea, also make it easier for you to catch HIV, probably by creating small sores through which the virus gains access to your bloodstream.
The opposite is also true.
If your HIV-positive partner has another STD he becomes more infective, probably because his viral load rises with infection and increased penile inflammation allows even more virus into his semen.
A multitude of other factors, including your health and your partner’s viral load, also influences your chances of being infected.
Although I
have seen statistics estimating that the average person needs twenty unprotected sexual encounters to contract HIV, I wouldn’t bet on it.
Having unprotected sex with the idea that you probably won’t catch HIV even if your partner has it is like Russian roulette—you never know which shot has the bullet.

Although much has been made about the risk of transmission between an HIV-positive physician and his or her patient, to date there is only one suspected case in the United States of HIV passing from a doctor to a patient:
the Florida dentist who transmitted HIV to his female patient.
The risk of infection for healthcare workers stuck with a needle from an HIV-positive patient is far less than 1 percent.
Blood transfusion is another area where risk has dropped significantly with the advent of routine donor screening.

The ELISA (enzyme-linked immunosorbent assay) test checks for viral antibodies in blood and is the mainstay of HIV testing.
Although very accurate, there are occasional false positive results among patients with chronic diseases, such as hepatitis and collagen vascular diseases (lupus).
For this reason, every test is repeated on the same sample of blood with the more specific Western blot test.
If this is also positive, you have HIV.

Confirmation of HIV antibodies by a second test before telling patients they have HIV had been the standard in this country to protect those few individuals who have a positive ELISA but negative Western blot test.
These patients do not have HIV but could be told they do after just one test.
In medicine, we routinely use phrases like “It looks like it’s cancer” or “You probably have an infection” for
many other illnesses before definite confirmation; not with HIV—until now.

In March 1998 the Centers for Disease Control reversed its previous long-standing policy of recommending two test confirmations of HIV before patients were told.
Now the Centers for Disease Control advocates an HIV test called the Murex rapid test, which provides results in as little as ten minutes.
This test also checks for HIV antibodies.
Positive results should be confirmed by Western blot, which usually takes an extra day.
Patients who test positive by rapid test are told that they are “probably” HIV positive but that another confirmatory test is needed.
The Centers for Disease Control reversed its policy because nearly 700,000 people take the HIV ELISA blood test each year but never return for their results.
It is hoped that patients will wait while rapid tests are performed.
Rapid tests also save patients from up to a week of needless anxiety while they wait for results by standard methods.
On the downside, some doctors do not agree with the Centers for Disease Control and worry that the rapid test is less accurate than the ELISA.

If a needle stick scares you, an OraSure test checks a sample of your oral secretions (not saliva) for HIV antibodies.
The test is as accurate as blood tests, and results are available in anywhere from three to seven days.
The downside is that most facilities do not have the capability to perform the OraSure.

No matter which test you choose, be sure to ask when you will have results.
They should take no more than two to three days.
Don’t submit to testing by anyone who tells you that it will take more than a week for an answer.
Get to a doctor or lab that assures a prompt response.