Stickman Readers' Submissions June 26th, 2012

HIV Reality Behind the Statistics

So I read HIV, Bargirls, and Statistics and
Some Feedback on all these HIV Stories. I can't help but mention a few gaping holes in the logic.

But first, let me state that accidental pregnancy and/or marriage by default to a bar girl may well be worse than HIV infection. No argument there. HIV can bankrupt you just like so many bar-girls-turned-wives, but at least, it won't
run amok wrecking your social network.

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So Stick had an interesting comment previously about why it was that, although he knew of HIV positive individuals, he had also heard plenty of stories of long-term sex tourists romping around irresponsibly, only to remain uninfected after
many years. While it is, in fact, possible to just get lucky, there's a more probable explanation: the CCR5-delta-32 mutation. Depending on which source you read, up to 10% of Europeans carry this mutation, which makes it impossible for them
to be infected by most HIV viruses. You see, HIV usually needs the so-called "CCR5 receptor" on a white blood cell's surface in order to infect it. Take the doorknob off, and it can no longer open the door. This is precisely what
occurs in the case of the CC5-delta-32 mutants. (A genetic test can tell you if you have the mutation.) However, make no mistake: not all HIV viruses require CCR5. Some other types of HIV use a different receptor, CXCR4. I'm not aware of
any natural mutation which knocks out this receptor. With all the research focused on CCR5, I expect a population shift at some point toward CXCR4-mediated infection. This is to say, individuals with the CCR5-delta-32 mutation had best consider
themselves infectable and use condoms.

Due to this mutation, you could easily have a sizable group of sexpats who live it up in the bars and never manage to get infected. (Even if they encounter a CXCR4 strain, the odds are low that they would contract HIV with a few unprotected
contacts.) They spread exciting stories of their deeds all over the web, and you get the impression that "eating healthy" or some modest behavioral change like that is going to prevent HIV. Look, I have no problem with prostitution where
the woman makes her own decisions. Marriage itself is just long-term prostitution in many cases. But let's be clear about this: if anything, individuals with a healthy immune system may actually be more likely to get HIV, because they often
have more white blood cells, which arrive on the scene to kill an incoming HIV infection, only to become infected themselves, and spread the virus throughout the body. To put it clearly, if you had no white blood cells, and thus no immune system,
you could not get HIV at all (although of course you could die from a common cold virus).

So the web is replete with stories about these "healthy" guys who never get HIV. It has very little to do with nutrition and a healthy immune system. It's just that they lack these receptors (or use condoms or get very lucky).

A bit more about receptors. Depending on the strain(s) of HIV which you acquire, and whether you have zero, one, or two copies of CCR5-delta-32, you might be able to survive for a long time without progressing to AIDS, in the absence of medication.
People with a single copy can still get HIV, but I've read that the virus tends to progress more slowly in such individuals, for obvious reasons.

Now, as to "HIV, Bargirls, and Statistics". Anonymous said that the transmission odds are around 1/1000 for a single act of heterosexual sex. It's hard to measure, but I suspect that he's correct about that, more or less.
But where it all goes wrong is when blood gets involved (roughly 10X higher odds, taking us to the region of 1% per act). Having no blood, but broken skin due to herpes or injury, would probably land the odds somewhere in between. But then he
goes on to say "If a man traveled to Bangkok and had unprotected sex with a different woman twice a night for 3 months every year for 10 years (930 sex partners) in a row, that man's chances of being healthy at the end of that decade
is… 99.53%." Hmmm let's do the math.

2 women a night for 3 months per year, for 10 years is 2x30x3x10=1800 partners, not 930. But let's assume he's half as aggressive, and it's really just 930 partners. And let's further assume that his transmission statistic
of 1/1000 is about right. (I would be surprised if it were that low, in this particular case, because he'd probably contract herpes at some point, which increases the HIV transmission rate, but never mind.) So, after the first sex act, he's
99.9% (0.999) likely to remain HIV negative. Hooray!

How about after the 930th act? He's then (0.999^930) likely to remain HIV negative, or about 39.4%. THIRTY-NINE PERCENT! That's a far cry from 99.53%. I'm not saying that Anonymous is trying to be irresponsible, but people's
lives are hanging in the balance. We need to get the math right. Granted, it may in fact be true that more sexpats are killed in traffic accidents than by HIV, or that bad bar girl marriages are worse still. But that doesn't mean that the
HIV threat is negligible.

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He also says that "With an HIV infection, even without retroviral drug treatment, a healthy person only has a 1-in-8 chance of actually developing AIDS." This might be a true statement, because many HIV positive individuals die
of liver failure instead of AIDS. The reason is that the medications are sometimes so overwhelming that it destroys their livers. (But yes, slowly, the drugs are improving with respect to side effects.) Now, for currently surviving HIV positive
individuals, we can't evaluate this statement at all, because they might yet develop AIDS. Does it really matter whether you die of liver failure or AIDS, if the root cause is still HIV infection? Good for you if you get the disease and end
up living like Magic Johnson, a long-term nonprogressor for over 20 years. But what if you don't? What if you get a CXCR4 strain and it explodes into AIDS in 8 years, or alternatively you bulldoze your liver, spleen, kidneys, pancreas, and
bank account in an effort to stave it off? What will you say then?

It's not all bad news. It's just that we're 10 or 20 years too early. The next generation of sexpats will likely relive the free sex era of 1960s (and get herpes, but it might be worth the fun). Why? Well, not because a vaccine
is coming any time soon. There was some minor success in 2009 with a Thailand trial. But I've read enough HIV literature to know that it's likely not meaningful. The virus mutates so rapidly and is so tiny that the immune system will
probably never have a sufficiently comprehensive idea of its "face" so as to recognize all future strains. However, stem cell therapy holds immense promise.

A company called Sangamo Biosciences (Google them) is doing several trials of a stem cell therapy targeting HIV. Or, to be more precise, to replace the immune system that HIV destroyed, with a version that cannot be infected by HIV. Basically,
it goes like this: use your own stem cells to produce copies of your own white blood cells, but modify the DNA so that the CCR5 receptor is no longer produced. (A later, similar trial will focus on the CXCR4 receptor.) Then culture them to produce
more copies, and inject them back into you. Eventually, HIV will eradicate your existing immune system. But it (sort of) doesn't matter, because these new cells will take over, and cannot be infected. It's still possible that HIV may
do other indirect systemic damage, but this is a minor issue relative to immune system collapse. If a new HIV strain emerges which uses yet some other receptor, then similar therapy could in principle be applied against it (billions of dollars
and many years later).

Knowing the American Food and Drug Administration, they'll let millions die of AIDS and liver failure for decades, so that the drug companies can land fat profits. Only after the drug patents expire, will Samgamo's treatments be
approved. (They might fail, but I doubt it. The preliminary results are quite compelling.) That's public "health" in America for you. On the plus side, someone else will likely copy the therapy. So my guess is that it will be available
in Asia within the next 5 to 10 years. If you're infected, then good luck finding a doctor you can trust. If you do, it just might save your life.

As to "Some Feedback on all these HIV Stories", I found the infection rate statistics very interesting. If true, they show very clearly how widely variable HIV infection actually is. It seems to depend heavily on the group of people
we're testing, even if they're all in Thailand or all prostitutes. It probably comes down more to condom use and risk aversion, than understanding HIV. Everyone knows that HIV kills. But most people don't have a clue how tiny risks
can compound into massive risks over the course of a career as a commercial sex worker, particularly in the absence of condoms. By the way, I'm not for one convinced that the HIV epidemic peaked here in the 1990s. People become complacent.
They hear about better drugs, and don't hear about the side effects. They hear about vaccine progress, and develop unrealistic hopes. But it's not just about infection rates. It's about drug resistance. The strains back then were
comparatively naive. They are easily controlled with drugs. But what happens when you get infected Western sexpats, many of whom having good access to drugs, mixing all their strains in a particular geographic area? You get the emergence of drug-resistant
strains. So you could have a bigger problem despite a lower infection rate. In that sense, the epidemic is worse now, even if (which I'm not convinced) the infection rate is lower than in the 1990s.

I love sexual freedom, too. I love it so much, in fact, that I want to make sure that HIV never takes it away from me!

Stickman's thoughts:

I just wish some really learned person without an agenda would pen the ultimate HIV article so we could all read it and understand it. With all the misinformation, misunderstanding and conspiracy theory out there, it's hard to know what to believe…

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