Dr. Kimberly Smith
Dr. Kimberly Smith, an infectious disease specialist at Chicago's Rush Medical Center, answers common questions about HIV and AIDS.
Q: What is the difference between HIV and AIDS?
A: HIV means you've been infected and the virus is in your system. AIDS stands for Acquired Immunodeficiency Syndrome. AIDS means that you have a compromised immune system as a result of the HIV virus. The disease qualifies as AIDS based on your T-cell count. When a T-cell count goes below 200, that automatically means a person is pretty significantly immunodeficient. The other way that a person's disease can qualify as AIDS is if they have one of the AIDS-defining opportunistic diseases. There's a list of those, and they are primarily infections that one typically would not acquire unless they have a compromised immune system. The most common one that people might recognize is pneumocystis pneumonia. In the early days of the epidemic, the majority of people who died of AIDS died due to pneumocystis pneumonia.

Q: Who is at risk for HIV/AIDS today?
A: Everyone is at risk of HIV/AIDS, based upon their behaviors. It is important for people to understand that there is no particular group that is more at risk than another group, unless they engage in more risky behaviors. Anyone from a teenager to a grandma is at risk if they engage in the behaviors that put them at risk. The main behavior is unprotected sex, in the broadest definition: penile-vaginal sex, oral sex or anal sex. All of those things will put a person at risk. Kissing, hugging or other contact where you don't share bodily fluids (semen, vaginal secretions and blood) doesn't put a person at risk. Saliva, tears, and urine are not a risk unless they are contaminated with blood.

Q: What demographics have the highest prevalence of HIV/AIDS?
A: The groups that have the highest prevalence are men who have sex with men and some racial groups, specifically African-Americans. This is true of men who have sex with men because the efficiency of transmission is greatest with anal sex, particularly if there is some trauma, or tearing, associated with it. Another reason, and this is true for both men who have sex with men and the African-American community, is that once you introduce an infection into a fairly closed community, and there are a lot of relationships within that community, it sort of self-perpetuates.
Q: What does it mean if you are diagnosed with HIV/AIDS today versus in the late 1980s and the 1990s?
A: In what we now refer to as the bad old days, which is really the late '80s through the the late '90s, when you had HIV it was pretty much uniformly fatal. Once a person had moved on to AIDS, the likelihood of them surviving more than a year or two was low. Now, if they get treatment, we can suppress their virus and we have every reason to believe that someone with HIV/AIDS can live a lifespan pretty close to what they would experience if they didn't have HIV. It's dramatic, there's no question about it. But there are some caveats to that. The earlier someone gets diagnosed, the better their long-term prognosis. If I find someone with HIV who's at an early stage and I put them on treatment, they will do a lot better than someone who's found when they have AIDS already. Those folks have more side effects from the medication, they're more likely to have complications related to the medication, they may already have opportunistic infections or malignancies. In that group, their prognosis is not quite as good. But even in that group, we still can significantly prolong people's lives. As long as they consistently take their medicines, get their virus suppressed and stay under a doctor's care, they're still going to live a long life.

Q: So the message here is ignorance is not bliss?
A: Absolutely. People must get tested. Back in the early days, people could say, "I'd rather not know because there's nothing you can do anyway." That certainly is not true now. There's a whole lot that you can do. And getting tested is not just important for the individual, it's important for society because once we suppress a person's virus, the likelihood of them transmitting the virus to another person goes down dramatically. We still obviously encourage people to have safe sex, always use condoms, but in the case that there are situations where the condom breaks, transmission is still very unlikely to occur from a person who has a suppressed virus.

Q: If you go to the doctor for a routine physical and they do routine blood work, will they test it for HIV/AIDs?
A: They will not. People have the misperception that when I say, "Doc, test me for everything," that means they are going to get an HIV test. That's not the case. Until recently, there was a lot of paperwork that went into having an HIV test. A lot of that has changed since the CDC [Centers for Disease Control and Prevention] changed their recommendations in 2006. Now you can do it with a verbal agreement, but the doctor needs to say to a patient "I'm going to test you for HIV unless you tell me not to." If you haven't had a conversation with your doctor about getting tested for HIV/AIDS specifically, you can assume you haven't been tested. If you're donating blood, part of the form you sign says that you're permitting them to test your blood for HIV and a variety of other things. If you test positive, they will definitely contact you and inform you that your blood tested positive and they recommend a doctor's care.
Q: If you have sex with someone who is HIV infected, how likely are you to get the disease?
A: The typical statistic that gets quoted is that with every heterosexual contact with an HIV-infected person, the risk is 1 in 1,000. But that is only an estimate and recent data suggests that that it is inaccurate and is probably the lower bound. Today we think your chance of contracting HIV with a heterosexual contact could be as much as 1 in 3. There are many things that affect your chances. If a person has very advanced HIV disease and a high virus level in their system, there's a greater likelihood that they will transmit. If the partner who is HIV-negative has an STD, like herpes or gonorrhea, that makes her more vulnerable to acquiring HIV. All of those factors play into the risk of transmission. I would say the range is anywhere from 1 in 3 to 1 in 1,000.

Q: Do all condoms work in the prevention of HIV/AIDS?
A: You need to use a latex condom and need to have spermicide. It can't be one of those lambskin condoms or other biologic ones which are supposed to improve sensation but don't protect against HIV. The female condom is another way that women can protect themselves. It is more under a woman's control and less dependent on a man, although it certainly requires that he be a participant. There are other ways to protect yourself that are being investigated, things like microbicides (a gel that you insert in the vagina that would prevent HIV) or a diaphragm that has anti-HIV drugs in it. A lot of new methods are being studied. Our hope is that in the near future women will have many more options than just a condom to protect themselves.

Q: There is a perception that it is difficult for a woman to transmit HIV to a man. Is that true?
A: That is clearly a misperception. The reality is that it is easier for a man to transmit to a woman, just based on anatomy and the biology of penile-vaginal sex. It's a little less easy for a man to contract it from a woman due to the same anatomical issues. But I think what's important for people to recognize is that around the world, the man-to-woman ratio of HIV infection is basically one to one. So about half of the people in the world that are HIV infected are men and half are women, and the majority of the transmission that takes place outside the United States is through heterosexual transmission. That means men are getting it from women.
Q: What's new about the 2006 CDC recommendations?
A: The recommendation used to be that you test people who you suspect has some risk factors for HIV—so if a person has multiple partners, a history of IV drug use or got a blood transfusion prior to 1985. Also, if they have any signs or symptoms suggestive of HIV or if they're a pregnant, those were the sorts of recommendations present before 2006. In 2006, the CDC made the important decision to recommend that everybody be tested, based upon realizing that pretty much everybody at some point in her life has had unprotected sex and you can't wait to identify individuals based on "risk factors." The specific recommendation from the CDC is that anybody from age 13 to 67 should be tested at least once, and if they have unprotected sex or other risk factors, they should be tested on a yearly basis.

Q: What is your message to women in their midlife who might be recently divorced or new to the dating scene?
A: I recommend that people always assume that someone you are going to be intimate with may have HIV or some other infectious disease, because there's nothing that you can tell by looking at a person that says whether or not they have HIV or any other sexually transmitted disease. I have some extremely healthy, beautiful people in my clinic who are HIV infected and doing well, but that doesn't mean they can't pass this disease on to someone else. If you assume that everyone could be infected, then you will always use protection. If you're going to have monogamous relationship with someone, then go down to your doctor's office or to the health department and have an HIV test together and share your results. Then you can feel confident that not only are you not infected but they're not infected.


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