Dear Dr. G,

I am ashamed to email you, but I am hoping to get some clarification about sexually transmitted infections, especially HIV.

I am a thirty-year-old heterosexual man, who is single. As I get rather lonely from time to time, I often have sex with women that I just met. And on several occasions, I did not use any protection.

I have also gotten involved with sex workers quite a few times. Of course, with such high-risk partners, I do use condoms. Sadly, on two previous occasions, the condoms broke and I was left terrified about contracting HIV.

One month following my exposure, I tested my HIV status and I am glad to say I was lucky to get away without it.

I would like to put Dr. G on the spot about the medical advancements in HIV transmission and treatment.

Can you tell me what is considered high or low risk sexual behaviour? Are there any numerical answers to this risk? Is it true the treatment after exposure is so good that it almost eliminates any chance of infection?

I also would like to know whether it is true that even in HIV-infected individuals, the treatment can suppress the virus to non-existence?

If all is true, isn’t it time everyone can afford to be a bit off guard on risky sexual behaviour?

Risky Rick

Medical professionals are commonly put on the spot to give precise risk stratification of an individual, after certain unintended sexual encounters.

The estimates for the likelihood are often conveyed as “high” or “low” risk exposure by clinicians. Though, many may find such generalisation evasive and unhelpful, especially when searching for a precise numerical figure for their risky exposure.

In reality, the precise risk levels of individual sexual activities are impossible to determine due to various reasons.

First of all, the HIV status of the other sexual opponent is often uncertain. Even for a positive partner, the stage of infection, virulence of the virus and viral load are important contagious factors.

Secondly, the quantity of infectious bodily fluid transferred can never be properly assessed, and whether the recipient has some degree of natural immunity to HIV is difficult to determine.

Lastly, the general states of health of both partners are also clearly important.

Regardless of the risk potential, many individuals would consider preventive medication started after exposure to the virus, in order to prevent the infection from occurring.

PEP, or post-exposure prophylaxis is a short course of HIV medicine taken very soon (72 hours) after a possible exposure to HIV to prevent the virus from taking hold in the body.

The idea of PEP was first applied to healthcare workers who are occasionally exposed to HIV through work, such as needle stick injuries. Such practice dramatically reduces sero-conversion amongst healthcare professionals when done under certain conditions.

Non-occupational exposure includes cases when a condom breaks or when a person with HIV has unprotected sex with a HIV-negative individual or has intercourse with an anonymous partner, also have similar success.

In 2005, the US Health and Human Services Department released the first recommendations for non-occupational PEP used to lower risk of HIV infection after sexual and needle sharing exposure, and this has become an important landmark for the prevention of HIV.

PEP is highly effective for the prevention of viral transmission. Studies have shown that PEP reduces the sero-conversion rates from sexual intercourse by 99% when taken daily.

Amongst individuals who inject drugs, PEP is less effective with a protection rate of 74%. PEP is much less effective if not taken consistently for one month.

PEP is for use only under emergency circumstances after unintended exposure. It is definitely not to replace regular use of HIV protection such as the use of condoms, as regular high-risk exposure may not have as effective protection with PEP.

Last Sunday (Dec 1), WHO observed World AIDS Day and data released demonstrated that of the 37.9 million people living with HIV at the end of 2018,79% received treatment and 53% had suppression of HIV reducing the risk of infecting others.

The success of the antivirals and PEP highlighted the differences thousands of healthcare workers are making to end the HIV epidemic, while is drawing global attention to the need for broader engagement.

In Malaysia, 3,293 new cases of HIV were recorded. Although the transmission via needle sharing is declining, 94% of new cases detected in Malaysia were due to sexual contacts.

The Hungarian-born pioneer and CEO of Intel, Andrew Grove once said: “Success breeds complacency. Complacency breeds failure. Only the paranoid survive.”

When complacent individuals ask about damping down the risk of HIV, Dr G is put on the spot.

For those hoping to be rescued by PEP after regular exposure to unprotected sex, his response is: “When it comes to unprotected sex, being off-guard is being complacent. Complacency will eventually catch you off guard. Only the paranoid, and monogamous, will survive and live happily ever after!”

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