Wednesday, October 24, 2018

ART Chronicles: CD4 Count and Viral Load

By: Ronald Bugarin


Every newly diagnosed Person Living with HIV (PLHIV) has to absorb a wealth of information about their journey towards and in treatment.  Among the multitude of terms to remember, most commonly used are “CD4 Count” and “Viral Load” but what do these terms really mean and how important are they to every PLHIV who are on Antiretroviral Therapy (ART)?


CD4 Count

CD4 cells (also known as T-cells, or T helper cells) are white blood cells that fight off infections that enter the body.  Its main function is to send signals upon entry of a virus or bacteria to other types of immune cells, including CD8 cells to fight off the cells infected by bacteria and viruses.


Upon successful HIV transmission in the body, the virus enters the CD4 cells and replicates after which, new copies of the virus will then be released and attaches to other CD4 cells. This ultimately opens the body to possible opportunistic infections due to the continuous decline of the CD4 and CD8 cells.

CD4 count is tested upon HIV diagnosis to check the current state of the immune system. Likewise, CD4 Count serves as indicators of possible risk of opportunistic infections and advanced HIV infection.  It remains as a vital test that can help HealthCare Providers (HCPs) in their decisions for empiric treatment, particularly for PLHIV with advanced HIV infection.

Below is a table showing the normal range of CD4 Count as well as PLHIV CD4 Count in cubic millimeter (mm3):

CD4  COUNT
IMMUNE SYSTEM STATUS
Between 500 to 1,500 cells/mm3
Normal CD4 range, immune system is healthy
Below 500 cells/mm3
Possibly immune compromised if PLHIV
Below 350 cells/mm3
Advanced immune compromised if PLHIV, with possible opportunistic infections

Since 2013, the World Health Organization (WHO) guidelines in administering ART to PLHIV has set the threshold to below 500 cells/mm3  to start with ART, giving priority to those with advanced HIV infection or with a CD4 Count of below 350 cells/mm3.  But in 2015, two large randomized controlled trials on the efficacy of ART at varying CD4 Count levels showed that starting ART, regardless of CD4 Count, has showed significant decline in the progression of the infection. Thus, WHO updated their guidelines in September 2015 to strongly recommend that all PLHIV start with ART regardless of their CD4 Count and to stop monitoring the CD4 Count of PLHIV who are already stable in their ART.

CD4 Count are measured prior to start of ART.  Upon ART initiation, CD4 count monitoring could be done every 3 to 6 months or upon ART failure.

Viral Load

Viral load (VL) is the amount of HIV present in your blood. The higher the viral load, the quicker a person’s immune system will be damaged, increasing their risk of opportunistic infections.  Also, viral load provides an early and more accurate indication of ART failure and the need for a change in ART combination, which also reduces the risk of drug resistance (HIV becoming resistant to the ART’s efficacy) among PLHIV.

Viral load of PLHIV should be monitored routinely at 6 and 12 months interval from initial HIV diagnosis and then every 12 months thereafter to ensure the stability of the ART and detect treatment failure earlier and more accurately.  Monitoring PLHIV who are linked to care is important to ensure successful treatment, to identify adherence problems and to determine whether ART regimens should be changed.


ART failure occurs when the viral load of a PLHIV exceeds 1000 copies/mL based on two consecutive viral load measurements within a 3-month interval.  Adherence support and counselling are needed following the first viral load test to prevent drug resistance.

An Undetectable viral load (less than 34 copies/mL), is the ultimate indication of ART’s effectiveness and is a goal that many PLHIV strive for. This is also crucial with the recent pronouncement of UNAIDS that PLHIV who adhere to their ART and have undetectable status can no longer transmit HIV.  Which means that ART adherence can be a way to stop the spread of HIV.


CD4 Count versus Viral Load

Upon start of treatment, ART suppresses the further replication of CD4 cells infected with HIV.  Upon viral suppression, the immune system then has a chance to recover naturally and ultimately fight off any opportunistic infections attacking the body.

The graph below shows the correlation of CD4 cells and viral load before and after ART initiation.  If a PLHIV does not start with ART upon diagnosis, the CD4 count decreases while the viral load continues to increase.  Likewise, when ART has been initiated, CD4 count slowly increases while the viral load decreases. Hence, CD4 count has an inverse correlation with viral load.

Image Retreived from: https://commons.wikimedia.org/wiki/File:Hiv-timecourse_copy.svg
Recent studies suggest that in situations where viral load testing is routinely available and individuals are virally suppressed (Undetectable), long-term CD4 Count monitoring adds little value and stopping CD4 Count for monitoring purposes will have major cost savings.

Below are the various CD4 Count and Viral Load Testing cost in selected hospitals / treatment centers:

Laboratory Clinic / Hospital
CD4
Viral Load
The Medical City I-REACT (Individual Rate)
1,715.00
13,900.00
The Medical City I-REACT (Group Rate)

6,230.00
Makati Medical Center
5,135.00
8,835.00
St Luke’s Medical Center (Global City)
2,575.20
8,689.60
St Luke’s Medical Center (Quezon City)
6,885.00
10,655.00
LoveYourSelf Anglo
1,500.00
7,500.00
San Lazaro Hospital
2,000.00
5,000.00
National Kidney Transplant Institute
4,600.00
4,900.00

CD4 Count and Viral Load testing are covered by the Outpatient HIV/AIDS Treatment (OHAT) Package of Philhealth per Philhealth Circular No. 011-2015.  Per Department of Health Administrative Order No. 2014-0031, CD4 cell count is done to alert physicians if the ART regimen has no effect in immune recovery or potential adherence issues. Declining CD4 count can be used as basis for switching ART combination but the measurement has to be repeated which can be financially straining on PLHIVs.  Also, where viral load monitoring is not available, clinical monitoring and CD4 monitoring are then recommended. A number of countries have either reduced the frequency of or stopped routine CD4 Count monitoring for PLHIV who are stable on ART and rely on viral load alone to monitor the response to ART and detect potential viral failure. As shown in the cost comparison table above, it is quite expensive to have regular CD4 Count monitoring on top of the viral load testing since the OHAT Package of Philhealth only covers the initial CD4 Count testing.


Whether CD4 Count or viral load is used as basis in monitoring ART effectiveness, it is also crucial to have a comprehensive and achievable adherence counselling for our PLHIV to empower them on their journey towards a stable immune status and long term HIV viral suppression.

For more information on HIV Treatment as well Life Coaching Services, you may visit LoveYourself Anglo and Victoria by LoveYourself

References:
  1. Undetectable = Untransmittable Public Health and HIV Viral Load Suppression
  2. Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection Recommendations for a Public Health Approach (Second Edition 2016)
  3. The Evolving Role of CD4 cell counts in HIV Care

Illustrations by:
TJ Gellada Monzon
Franco Moje
Mark de Castro
(Inspired by the Japanese manga series “Cells At Work”)

Monday, October 08, 2018

HIVisions: Hearing and HIV

By Carlos Diego A. Rozul

From the booming sounds during a party to the gentle whispers from a significant other, the sense of hearing plays a significant role in making our days more vibrant. For hearing people, it is an essential to understand and appropriately respond to verbal communication. In recent years, researchers[1] in the field of HIV care has put their attention towards the hearing health of people living with HIV (PLHIV). A 2013 integrative review by Assuiti, Lanzoni, dos Santos, Erdmann, and Meirelles[2] revealed that there was not enough evidence for a direct association or implication of antiretroviral therapy (ART) and hearing loss, however they suggested to investigate the associated factors further due to inconclusive data.

Image retreived from https://www.flickr.com/photos/photobythomas/11535403595/in/album-72157644872472185/
Hearing Complaints among PLHIV

According to van der Westhuizen, Swanepoel, Heinze, and  Hofmeyr[3] PLHIV were more likely to report auditory and otological symptoms such as tinnitus, vertigo, and otalgia due to otitis media while a few others have reported sensorineural hearing loss, especially for those who are in the advanced stages of the infection. It was previously suggested[4] that this was due to the direct action of the virus on the central auditory system, however there is also evidence pointing towards it acting upon the peripheral auditory pathway as well[5], which occurs more often when viral load is high.

Two major concerns for people living with HIV who are not enrolled in treatment are co-occurring infections that one may have when first infected, and opportunistic infections. When it comes to risk for hearing loss, CMV infection[6], bacterial meningitis[7], otosyphilis[8] are of the most concerning. Due to non-treatment, PLHIV may become immunocompromised wherein their immune system becomes less effective defending against pathogens. As such, those related to the neural and auditory system may significantly affect one’s hearing. With adherence to treatment however, these concerns are eliminated.

Image retrieved from: https://pixabay.com/en/pregnancy-woman-asian-2594275/
The Case with Pregnant Women Living with HIV

Aside from the mother, there is additional concern for the child a woman carries when she is infected with HIV. Maternal health and health behaviors can influence the development of the child, as such they are even more vulnerable for prenatal TORCH infections - one of the most common causes of congenital hearing loss. Among these are toxoplasmosis which has 70% incidence rate of hearing loss[9], rubella which is declining due to immunization programs[10], CMV wherein 33-50% of hearing loss incidences have late onset[11], and HSV which is transmitted when the child is delivered vaginally[12].

Image retrieved from https://www.flickr.com/photos/niaid/32483530942
Antiretroviral Medication and Hearing

Past studies[13] have shown a trend of higher hearing thresholds among PLHIV on treatment as compared to non-infected individuals, however inconclusive with regards to the mechanism of action[2]. Findings are mixed with some suggesting that components of some ART combinations such as nucleoside analog reverse transcriptase inhibitors[14], Epzicom, and Trizivir[15] have the potential to adversely affect hearing; while others suggest that HIV infection and ART adherence have no impact on cochlear function.

Image retrieved from https://www.facebook.com/PHnewbornhearingscreening/
In some ways, living with HIV and hearing loss are quite similar. Both are silent conditions that can only be identified when one decides to get tested. However, they do not need to coincide. Treatment is readily available for PLHIV in the Philippines to prevent any opportunistic infections that can cause hearing loss. The Universal Newborn Hearing Screening and Intervention Act of 2009 also ensures that all newborns, regardless of risk, are screened for hearing loss.

So talk to your doctor if you have any concerns with your own or your child’s hearing.  You can be referred to a Certified Newborn Hearing Screening Center or Hearing Center near you.

References
  1. https://www.audiology.org/news/hiv-and-hearing-loss
  2. http://www.scielo.br/pdf/bjorl/v79n2/en_v79n2a19.pdf
  3. http://yvdwaudiology.co.za/wp-content/uploads/2017/05/2013_Westhuizen-Swanepoel_IJA.pdf
  4. https://bmcinfectdis.biomedcentral.com/track/pdf/10.1186/1471-2334-6-28
  5. http://www.producao.usp.br/bitstream/handle/BDPI/9160/art_MATAS_Avaliacao_auditiva_na_Sindrome_da_Imunodeficiencia_Adquirida_2010.pdf?sequence=1
  6. https://www.sciencedirect.com/science/article/abs/pii/S0753332297823268
  7. https://www.researchgate.net/profile/Elizabeth_Molyneux/publication/8963254_The_effect_of_HIV_infection_on_paediatric_bacterial_meningitis_in_Blantyre_Malawi/links/02bfe50f78a79cb76f000000/The-effect-of-HIV-infection-on-paediatric-bacterial-meningitis-in-Blantyre-Malawi.pdf?origin=publication_detail
  8. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-3083.2004.00939.x
  9. https://www.ncbi.nlm.nih.gov/pubmed/8770668
  10. http://www.bioline.org.br/request?hg06026
  11. https://www.jpeds.com/article/S0022-3476(99)70328-8/ppt
  12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4222184/
  13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4081880/pdf/cln-69-07-469.pdf
  14. https://academic.oup.com/cid/article/32/11/1623/464432
  15. https://www.ncbi.nlm.nih.gov/pubmed/24487230
_______________________________________________________
Carlos Diego is an HIV counselor and the Head of Editorial for LoveYourself. Outside of volunteering, he is a clinical audiology student and a registered psychometrician. He aims to facilitate a deeper meaning to health by discussing the importance of aural, sexual, and mental health.

Friday, September 28, 2018

Transitioning and the Call to Love

Jan Gabriel M. CastaƱeda



If you search for “transition” on Google, it actually gives a specific definition for gender transition: to “adopt permanently the outward or physical characteristics of the gender one identifies with, as opposed to those associated with one's birth sex.” It’s an incomplete definition, of course: it’s not just outward characteristics that change. Neither are they always the most important changes which that assume such changes happen at all: being transgender doesn’t always mean having extreme discomfort with the body you’re born with, as we’ll talk about later. But transitioning, in whatever form it takes, does mean a change that radically alters an individual. Many transgender people, very appropriately, refer to this as a “journey”.


While we are talking about transgender people specifically, it’s helpful to note that every person “transitions” at many points in their lives. We transition when we grow up and take on new responsibilities. We transition when we leave a place or a profession. We transition with every joy and tragedy, like the birth of a child or the death of a parent. Other transitions take place subtly over long periods of time, like when a person acclimates to living in another country. All of these transitions take place in different contexts, and while there are definitely patterns in the stories people tell, each person brings their own memories and imaginations into them. There is no single way of transitioning in any way for any person, so the possibilities are as endless as our capacities to imagine them. Think about your own transition from grade school to high school, and see just how different these experiences can be between you and your classmates. You may not have even transitioned to high school at all, and your life may have moved in a different direction.

For many transgender people, these periods of transition are numerous, with many goal posts, successes, disappointments, beginnings, and endings. I invite you to ask your own transgender friends and see what stories they have to share.



Types of Transitioning for Transgender People

In medical, psychological, and rights-based language, you find a distinction between “medical” transitioning and “social” transitioning. The history of this distinction is interesting in itself and some aspects of one can very well overlap with another. Medical transitions refer mainly to changes to one’s physiological makeup. This includes changes things such as the endocrine system (e.g. hormone replacement therapy) or to one’s physical sex characteristics (e.g. gender-affirmation surgery or also referred to as sex reassignment surgery). Many transgender people strongly believe that being able to change one’s body is important so it matches how they see themselves in their hearts and minds. (If you think about it, this is precisely what a lot of people who beef up at the gym do. The only difference is that people who work on their fitness are seen as culturally appropriate.) But just as many don’t feel that way. One person’s journey might involve extreme discomfort with their bodies, brought about perhaps by their society’s obsession with the physical body and its obsessive stereotyping of people based on what they think genders can or cannot be. Another journey might not have such discomforts, and the struggle could be elsewhere. Both journeys are equally true and meaningful.


Social transitions on the other hand refer to changes in a person’s social, cultural, and political life. These don’t necessarily require medical intervention. This includes many of the things we are familiar with, like dress, behavior, and ways of relating to others. On the transgender person’s side of things, this can include wearing the clothes that match the gender they identify as, coming out as transgender to friends and family, and adopting habits that we might associate with their identified gender. On the side of those around them this might include using the pronoun they ask us to, referring to them by the name they adopt for themselves, and other things. The point here being that transitioning is about aligning their inner experience of gender and their outward expressions, and that those around them are also part of this process.

Responding to transitioning affirmatively

In the Philippines, as in many places here in Southeast Asia, the transitioning process of a transgender person appears to go against many long-standing cultural values. People believe that gender can only ever be lalaki or babae; that a person is born into these roles by virtue of their reproductive organs; and that these are unchanging facts of biology, history, and morality. Historically, this was not always the case, and there many reasons for this. But what’s important is that these beliefs have consequences. In this case, the consequence is that we are left unequipped for such transitions. Our cultures has many tools for, say, a death of a parent: the wake, the funeral, the various types of behaviors recognized as grieving, the general understanding that you need time to deal with this strange experience, and so on. It is only in the past few decades that we have started imagining and creating such cultural tools for those transitioning from the gender they were assigned at birth to the gender of their hearts.

The reference to death is not accidental. Many families I’ve had the opportunity to know do describe their experiences in these terms. They talk about the “death” of a person they once knew, the death of the boy or the girl they raised from birth, that sort of thing. As unnerving as it is, there’s a good reason “death” is the word they use. When we listen more closely, they are not expressing not violent horror or malicious rejection (though this is definitely the case for others and we cannot ignore that suffering); they are expressing confusion and pain, both misplaced and misunderstood, and a genuine desire for the love to push through. In the average person I meet, it is ignorance and not blatant transphobia that makes them do sad, hurtful, and stupid things. But certainly we can avoid a lot of the sad, hurtful, and stupid behavior altogether.



In the case of transitioning, part of making our culture more affirming to the transgender person’s experience is by changing this core mindset. Death need not be terrifying or negative. In funerals, we often have storytelling and eulogies of the beautiful life who has left us, and we have songs and silent contemplation about how that beautiful life can teach us so our own lives in the present can be beautiful too. They can and should be celebrations. And what I often say to the families I’ve met is that nobody has actually died: their brother and sister, their son or daughter, is still there, and there is a new phase of life that has the potential to be full of beauty if we allow it. We don’t need to think by ourselves how a person’s life can enrich our own; that person is there waiting to live life with you.

The fist point I’d like to make here is not for the transgender person, but for the people around them. This is difficult, but the first thing we all need to do is to stop all the moralizing and gut responses of anger and disgust. All that talk of immorality or unnatural is both scientifically and logically incoherent. But the worst part is that all that talk keeps us from recognizing the real issue: that this experience of having a friend or family member who is transitioning does not make sense and it is deeply troubling to you. And if you look closer, you may also discover that you are troubled because something is getting in the way of your love. Put simply, it would not be so distressing or confusing if you did not care. But you do care. You love them, and that love shines bright and true through the haze of that confusion. But you don’t know this person anymore. In a sense, this is true: the person you imagined you friend or family member would be, is not who you expected or perhaps wanted to be. So who do you love now? And how do you love them?

Some recommendations from love

The question of how to love emphasizes the point that transitioning, especially in the context of the average family, is not a one-sided affair. Everyone needs to transition. While it’s not always the case, some may need grief or some other emotion to deal with the shock. But when the dust has settled, everyone needs to get to know all over again their transgender child, or uncle or aunt, or brother or sister. It’s not kuya anymore, but ate. It’s not Jason anymore, but Janice. It’s she, not he. There may no longer be marriage or grandchildren, or maybe there will be, but that’s another story altogether. The words and names you grew up with are no longer appropriate in the light of new circumstances, and that can be deeply disturbing to many. Again, who do you love now? How do you love them? Progress is when we start asking these questions frankly and openly.


Love demands a lot of things. But perhaps the most relevant are patience, openness, and hope. This is good advice for both the transgender person and everyone around them. When we say patience, we acknowledge that this is going to take time. You need to get to know your transgender friend or family member, and getting to know them means recalibrating that sense of the world that has taken you your entire life to put together. This may or may not be a lot of hard work depending on where you’re coming from, but it is going to be work regardless. Something has to replace your old sense of the world. For the transgender person, this may include uncomfortable questions about whether someone is worth the hassle. Bridges may be mended or burned, as in any other kind of transition in life. Those are the options our present reality, with all its prejudices, has given us. But with imagination, these painful decisions can be a good thing. “When I transitioned, I found out who my real friends and family were” is a very common sentiment I hear from transgender people. And it’s a sentiment borne of an imagination that makes growth possible amidst truly unpleasant and even terrifying experiences.

As for openness, it’s not just about openness to new information; it’s about openness to experiences you’d rather not have, and to appreciate them as painful but necessary goalposts to your development as both a person and as a component of the family or friendship network you belong to. You are confused, and maybe even angry, because your son is now your daughter. Of course you are. Who wouldn’t be? But you’re not confused or angry because your child is transgender: you are confused and angry because so many of your dreams, desires, and expectations of your child are now moot. And you are confused and angry, most of all, because you are not sure how best to love your child anymore. Patience requires that we go through the motions of recalibrating all those dreams, desires, and expectations, but openness requires that we be open to the possibility that this has to happen. If we do not, then we remain stuck in confusion and anger because the roots of these emotions are not being allowed to change. The same is as true for the transgender child as it is for the parent: your own dreams, desires, and expectations about your relationship with your parents may need to change. This may or may not be pleasant, but you need to be open to it regardless.

Finally, there’s hope. You don’t just work through a thing and be open to whatever that thing throws at you: you look forward to something in return. You, your family, your friends – everybody involved needs to be committed to a vision of a future that sees everyone flourishing. It’s not an uncommon idea: all of medical science, all of psychology, and all of humans is built on the fundamental assumption that our work will help humankind flourish. Such that whatever the journey transgender people have, whatever the transition process might entail, everyone comes out better and stronger human beings.

For more resources on social transitioning, you may visit Victoria by LoveYourself (VLY) in Pasay City.

Images by: Franco Honesto Lasay and Mark de Castro
________________________________________________________
Jan is currently Program Associate at ASEAN SOGIE Caucus, a network of LGBTIQ human rights activists in Southeast Asia working towards the integration of sexual orientation and gender identity and expression into the broader human rights work in the region. Jan is also a member of the LGBT Psychology Special Interest Group of the Psychological Association of the Philippines, which works towards an LGBT-inclusive practice of the discipline of psychology in the Philippines.