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HIV - no longer a death sentence but a period of hopeful living

On World Aids Day today, one doctor presses home the message that an HIV diagnosis these days is not a death sentence, and that the disease can be managed like a chronic illness, kept under long-term control with medication.

"I wish things were different."

I hear these words often, especially as an infectious diseases physician who cares for patients infected with HIV. These words encapsulate so much of the experience of being diagnosed with, being treated for, and living with the condition: the uncertainty, the fear, the regret, the challenges faced every day.

The landscape of HIV medicine has changed vastly in the past decade - treatments are now much more tolerable, affordable and effective; HIV testing technology has become much more sensitive and accurate; and people with HIV are living longer, healthier lives than could ever have been imagined during the dark early years of the epidemic.

For me, convincing my patients of these changes is one of the more challenging parts of the job.

THE 90-90-90 GOAL
I first treated A two years ago, when he was first diagnosed. He was tested at a polyclinic following a bout of gonorrhea, and when the HIV test result came back positive, he was referred to my clinic at Tan Tock Seng Hospital's Communicable Diseases Centre.

A is in his early 40s, works in finance, and has been married for the past 10 years. I remember vividly that he seemed almost unsurprised at his diagnosis - because, as he revealed, he had had several indiscretions leading to his sexually-transmitted infections in the first place. He was also fairly well-informed about the condition, and seemed keen to start treatment early.


ST ILLUSTRATION : MIEL

It was when I broached the topic of informing his wife about his diagnosis that he showed the first signs of distress.

"I can't do that! She'll leave me!"

"But what if she's been infected too? Wouldn't you want her to be diagnosed early too?"

"But - "

"Think about it, A."

A had been diagnosed early, when his immune system was still intact and he displayed no signs or symptoms of being infected.

International guidelines for the management of HIV now universally recommend starting treatment as early as possible to preserve the health of the immune system. However, statistics from the Ministry of Health still show that half of all new diagnoses of HIV infection in the country are made at a late stage - when complications have already set in.

The Joint United Nations Programme on HIV/AIDS has set out ambitious goals for the global HIV/AIDS response. The "90-90-90 Treatment Goals", which will be a key topic of interest at the Singapore AIDS Conference 2016 to be held on Saturday, aims to have 90 per cent of all HIV-infected individuals aware of their HIV status, 90 per cent of all HIV-diagnosed individuals on HIV treatment, and 90 per cent of all those on HIV treatment with undetectable viral loads by 2020.

These ambitious targets are needed as part of a vision of no new HIV infections in the future. It is hoped that by achieving 90-90-90, the world can reach zero new HIV infections - if everyone who is infected is diagnosed and treated, then the risk of onward transmission to others will also decrease significantly.

However, it is contingent on people coming forth early, getting tested, linked to care and staying in care to succeed.

HIV AND STIGMA
Then there's D, another patient I had been seeing for several years. He was a final-year university student when he first walked into my clinic, a week or two after he had had an HIV test done at an anonymous test site. As so many do when they first receive the news of their diagnosis, he asked me how long more he had to live.

"If you start treatment, and stay on treatment, then you can expect to live a normal lifespan."

"Are you sure?"

"That's what the science says."

I saw in his face the spectrum of emotion that I've since grown used to seeing when telling patients this news: the surprise, the disbelief, the hesitant relief.

"But you will need to adhere to your treatment, of course."

The practice of HIV medicine has become one of chronic disease management - with highly active antiretroviral therapy, people diagnosed with an HIV infection today are expected to have a normal life expectancy.

This does come with its attendant challenges: lifelong medication, regular medical appointments, and dealing with the complications of both the disease and its treatment.

As an HIV physician, I am still discovering every day how my patients live with HIV. During one of our many conversations, D told me that he no longer thinks of himself as suffering from a disease, or even living with one.

"I am living my life, and HIV just happens to be one of many parts of that life."

To that end, the provision of HIV care is also continually changing and adapting. Patient-centred HIV care looks to be the new frontier - providing multi-disciplinary medical and para-clinical services in a way that is most acceptable and accessible to those who need it. These include community right-siting of HIV services, the use of tele-health platforms, and exploring ever more convenient and tolerable HIV drug regimens.

D learnt of his HIV diagnosis not long after coming to terms with his own sexuality. He has felt the stigma associated with being both a gay man, and someone living with HIV.

His is a common story - that of a life lived in secrecy, even from those close and dear to him.

The stigma of HIV/AIDS, and the discrimination faced by those who live with it, can have devastating consequences.

It is well recognised that people living with HIV/AIDS suffer more from psychiatric and psychological disorders and have more difficulty securing steady employment and housing.

It has also been found that the real, and perceived, stigma of the diagnosis is a major barrier to people at risk seeking HIV testing and treatment: why find out when it would only mean more shame?

Despite the fact that we have been fighting the epidemic for more than three decades now, and have made major steps on the medical front, further progress is an uphill task unless societal views change as well.

If those who are at risk of HIV, or who are already living with HIV, continue to feel blamed or shunned or set apart, then we will never be able to present the united front that is needed to truly defeat this scourge.

TREATMENT AS PREVENTION

I last saw A and D very recently. Both are doing very well on treatment. They have undetectable viral loads, which means that their medications are working to suppress the virus in their bodies, allowing their immune systems to function healthily.

A did eventually tell his wife, and after a bit of a rough patch, they were reconciled. His wife tested negative for HIV, and now they want to have another child.

D graduated from university, and is now working in a regional sales job. He recently met someone special, and has told his partner that he is HIV-positive.

The field of HIV prevention has also advanced rapidly in recent years. In addition to the well-worn messages of safer sex and condom use, the principle of "Treatment as Prevention" is one of the foundations of modern HIV care. By diagnosing and treating HIV early, we reduce the likelihood of HIV-positive people transmitting the infection to their sexual partners.

What's more, the stage is now set for the adoption of HIV Pre-Exposure Prophylaxis, or PrEP. This refers to the use of antiretroviral medications (specifically, the two-drug combination) by HIV-negative individuals to prevent HIV infection.

PrEP has been extensively studied in various populations, including gay men, heterosexual men and women, and HIV serodiscordant couples (where one partner is HIV-positive and the other is negative), and has been found to be effective and safe.

I am thankful to be able to practise in an age when HIV/AIDS has become something manageable and no longer a terminal diagnosis. I am also humbled to be a small part of the lives of those I have the privilege to call my patients.

I was taught by one of my mentors (a senior physician on whose giant shoulders I now stand) that the noblest thing a doctor can aspire to do is to promise to walk alongside his or her patient on the long road to being well.

This is a promise I make to all my patients, and perhaps one we can all consider making to those around us who are struggling and alone.


•Dr Wong Chen Seong is a consultant at the Institute of Infectious Diseases and Epidemiology at Tan Tock Seng Hospital.

A version of this article appeared in the print edition of The Straits Times on December 01, 2016, with the headline 'HIV - no longer a death sentence but a period of hopeful living'. Print Edition | Subscribe