TERRE HAUTE, Ind. » Treatment of HIV positive patients has come a long way since the early 1980s, when it was considered a death sentence.
Because of advancements in medicine, today, "It’s an outpatient disease," Dr. Imad Koj, a Terre Haute internist who works with patients who are HIV positive, told the Tribune-Star. He is an infectious disease specialist who has practiced in the community since 1999. When the epidemic began, "We didn’t have any treatments at that time," he said. "We used to have wards full of patients in the hospitals when I was training in New York."
The prognosis improved thanks to the development of HAART, or highly active antiretroviral therapy, which involves the use of multiple drugs or "cocktails" that act on different viral targets. Continuing advancements in drug therapy "have improved the outcome and decreased the mortality rate," he said.
The lifespan and prognosis for someone with HIV "depends on the patient and compliance and adherence with the treatment," he said. If they continue their treatments, they can live long, healthy lives. He has worked with patients since 1999 who are HIV positive, and "they are still doing OK."
Patients diagnosed as HIV positive can become "undetectable" within a few months of starting treatment and remain "undetectable" for the rest of their lives, he said. He’s had patients "undetectable" for 17 years.
"Those patients usually do very well," he said.
But "undetectable" does not mean "cured." An undetectable viral load means that so few copies of the virus are present in the blood that monitoring tests are unable to detect them. Even with an undetectable viral load, an HIV-positive person still has the virus.
Once a person is diagnosed as HIV positive, the person will always be HIV positive, and the risk of transmission remains, Koj said.
"We should always educate patients that the risk of transmitting the disease is lower when you are undetectable, but the virus could still be present in some components of the blood," he said.
Those who are HIV positive must continue with treatments to keep the disease from advancing. Treatment usually involves several drugs combined in one pill; the drugs kill the virus (lower the viral load) and increase the immune cell count, Koj said.
AIDS is defined by the presence of opportunistic infections or a significant decrease of CD4 (immune cell) count to below 200. "We rarely see that nowadays," Koj said.
HIV is making headlines in Indiana, with a serious outbreak in Scott County in the southeastern part of the state and last week’s revelation that someone in Vigo County has knowingly spread HIV to others in the community. That person is not currently a threat, officials say.
In southeastern Indiana, primarily Scott County, 142 new HIV cases have been reported since December, prompting the intervention of the state Department of Health and Centers for Disease Control and Prevention.
In Terre Haute, several sites offer HIV testing, and representatives hope to increase awareness about the importance of testing, especially for those involved in high-risk behavior, including those who have multiple sex partners, have unprotected sex or share needles to inject drugs.
Planned Parenthood of Indiana and Kentucky, which has 23 health centers in Indiana (including Terre Haute) and two in Kentucky, conducted more than 8,000 HIV tests between July 1, 2013 to June 30, 2014. The centers also performed 27,000 tests for gonorrhea and chlamydia, said spokeswoman Tammy Lieber.
The Terre Haute clinic provided 150 HIV tests and 392 tests for gonorrhea and chlamydia in the same time frame.
"We do HIV testing based on risk factors. Our nurse practitioner determines risk factors and whether HIV testing makes sense," Lieber said. If the client chooses to have an HIV test, the health professional explains the test, which is an oral swab that provides results in 20 to 40 minutes; the test detects antibodies.
If positive, the next step is a diagnostic test that takes a few more days and is sent out for results. The client returns, and the results of that test are delivered in person at the Planned Parenthood office. If positive, the client will meet with a Planned Parenthood staff member and someone from Positive Link, part of IU Health Bloomington Hospital, which provides a continuum of services for those impacted by HIV in south central and southwestern Indiana. Services include prevention as well as social services for those who are HIV positive.
Lieber believes there is a lot of risky behavior that goes on, and "I don’t think we can assume that risky behavior is limited to (southeastern Indiana)."
Kim Naeseth, community health educator with Positive Link, said that one in five people living with HIV aren’t aware of the infection because they have no symptoms; it can be years before symptoms begin. That’s why testing is so important. "Anyone who is sexually active or an injection drug user should be tested once year," she said.
Positive Link provides free HIV testing from 1 to 4 p.m. Mondays at Booker T. Washington Community Center in Terre Haute. They use an oral swab called OraQuick, which produces results in 20 minutes.
Positive Link also has a care coordinator, who works to ensure those diagnosed with HIV have insurance and access to necessary treatment and medications; the care coordinator also makes sure the patient’s emotional and financial needs are met.
"HIV disproportionately affects poor people," and they may need other services such as a safe place to sleep, bus pass or gas money or need help with groceries, Naeseth said.
If someone tests positive for HIV, the testing agency must provide the person’s name to the Indiana Department of Health, and a regional disease intervention specialist would make contact with the HIV positive person to talk to them about other people who have had potential exposure. "The state would be the only organization it is reported to if someone tests positive," Naeseth said.
An HIV-infected person must be informed of Indiana’s "duty to warn" law, which means they must tell past, present and future sex or needle-sharing partners of their HIV positive status. The disease intervention specialist can notify past partners for them without using the infected person’s name.
While some people may have thought HIV was no longer a problem, recent events in both Scott and Vigo counties indicate otherwise. "HIV is still definitely an issue," Naeseth said. Vigo County has the third-highest prevalence of HIV in the state, according to the state Department of Health.
In 2014, Vigo County had 11 new HIV/AIDS cases reported, and the total number of people living with HIV/AIDS, including cases diagnosed in other states and now living in Indiana as of Dec. 31 — was listed at 274.
Those with high-risk behaviors should test once a year, she said. Important ways to reduce the risk of HIV transmission, or any other sexually transmitted infection, include using latex or polyurethane condoms "correctly and consistently," she said. Also, injection drug users should not share needles.
Among the clinics in town that provide HIV testing is PACE Health Connection, at 501 Hospital Lane, Suite 101 in Terre Haute, next to Terre Haute Regional Hospital. Its focus is on family planning, but it does offer HIV tests.
The test, OraQuick, is an oral swab that involves collecting fluid from a person’s gums; no blood is required.
The community should be concerned about HIV, said Rebecca Skiver, PACE physician assistant. With the number of confirmed cases listed as 274 in Vigo County for 2014 , "I absolutely think it’s something people need to be aware of and be cautious of and be proactive in preventing," she said.
She’s believes many people are putting themselves at risk, especially young people ages 19 to 26. High-risk behavior involves multiple partners, unprotected sex and IV drug use. "I’ve been here about 13 years, and even in that time I’ve really seen a change in people’s attitudes" related to sex, she said. "It’s very casual, you don’t necessarily know your partner. It’s something done for fun and not necessarily intimate relationships."
It’s leading to more partners and unprotected sex, she said. While college-age students should be knowledgeable about the risks, part of it might be the "I’m a little bit invincible attitude," she said.
While Health Connection regularly does HIV testing, the Terre Haute office hasn’t had someone test positive in several years, Skiver said. In the past, she has provided support to those who have tested positive. When they find out, "They need someone to talk to, to maybe vent. I had someone extremely angry, and I had to listen to them yell for quite awhile." She remembers someone else who was solemn, and "we just talked."
She also described a medication that can prevent someone who engages in high-risk behavior from becoming infected with HIV. Pre-exposure prophylaxis, or PrEP, is a way for people who do not have HIV— but who are at substantial risk of getting it — to prevent HIV infection by taking a pill every day.
"It’s shown to be very effective," Skiver said.