'There is now a deadly virus, which anyone can catch from sex with an infected person. If we’re not careful, the people who’ve died so far, will be just the tip of the iceberg… If you ignore Aids, it could be the death of you.’ It has been hailed as one of the most memorable health campaigns ever created. The message couldn’t have been clearer and people were petrified. For anyone over the age of 30, the ‘Iceberg’ and ‘Tombstone’ adverts — as they came to be known — with John Hurt’s menacing voice-over, still bring back a sense of crushing dread. The UK actually led the way with its HIV public health campaigns; it was considered so successful in raising awareness that other countries adopted similar adverts relying on shock and fear. The thing I am most struck by now, however, is how over-the-top they seem.
It’s now 30 years since HIV was discovered. During my training as a doctor in central London in the late 1990s, people were still dying of Aids. But since then, incredible pharmacological advances have been made in how the virus is treated and managed. Combination medications — termed ‘highly active antiretroviral therapy’ or Haart — have resulted in being able to maintain the infected person’s immune system and therefore prevent the opportunistic infections that resulted in the development of Aids and led to death. Despite working in the centre of London with high-risk groups such as sex workers and drug addicts, I haven’t seen someone die of HIV for years. It’s now incredibly rare to die as a result of HIV/Aids in this country. The most recent statistics show that in 2012, less than 1 per cent of people with HIV died. This is about the same for the non-infected population. It’s hard, now, to argue that HIV is a death sentence.
Those who are dangerously unwell with the disease are often immigrants who have been infected for years, and present to hospital late with the kind of infections that we no longer see in those on medication. One study suggested that around 75 per cent of HIV-related inpatient admissions are immigrants, with about 60 per cent from Africa. For the vast majority of people with HIV in this country, though, the disease is managed entirely in outpatient clinics. HIV/Aids wards and specialist units have closed simply because there is no longer the volume of patients to fill them. This is a hugely encouraging fact, which would have seemed impossible to those who stood, in the 1980s and 1990s, as friends, family and loved ones faded away while doctors stood by utterly helpless. What is truly startling is the speed with which medicine responded to HIV.
A recent large epidemiological study showed that, for those diagnosed with HIV now, life expectancy is similar to someone who does not have the virus. The medical profession now considers HIV a chronic disease; it’s regarded in public health terms in the same category as, for example, type 2 diabetes. As a doctor I can tell you that, medically speaking, I’d rather have HIV than diabetes. While this might sound shocking or surprising, the facts speak for themselves: the prognosis for those with type 2 diabetes is much worse than for those with HIV. The risk of stroke in newly treated type 2 diabetes is more than double that of the general population. People with diabetes are four times more likely to have cardiovascular disease than someone without diabetes. In 20 to 30 per cent of people with diabetes, there’s damage to the kidney filtering system leading to kidney failure and the need for dialysis. Damage to the delicate vessels in the eye is a leading cause of blindness and damage to nerves is a leading cause of foot wounds and ulcers, which frequently lead to foot and leg amputations. For those with HIV, providing they take their medication, there are very few problems.
Many people are complacent about diabetes in a way that would seem reckless with HIV. People consider type 2 diabetes an irritant — something that can be easily fixed with tablets. But this is wrong. Regardless of how well it is controlled, type 2 diabetes is a progressive disease, which results in the need to increase pharmacological therapies over time. A recent study conducted in Australia showed that, after six years, 44 per cent of patients no longer responded to oral medication and required insulin injections. Oral medications eventually fail in most people, meaning that injections are almost inevitable at some point.
Now compare this with HIV. Fixed-dose medications (multiple antiretroviral drugs in a single tablet) have meant that most of those infected simply take a tablet a day. While no one wants to have to take medication for the rest of their lives, it’s a lot easier than injecting insulin. And of course there are side effects, but that’s true for diabetes medication and, with a bit of trial and error, most people find a medication that suits them. To put it starkly, the latest statistics show that because of Haart, HIV now no longer reduces your life expectancy, while having type 2 diabetes typically reduces it by ten years. But this isn’t an easy thing to say publicly.
The news about our incredible progress against HIV is only whispered about because there are concerns that if it is emphasised, then people will no longer take care to avoid infection. The HIV charities, full of older gay men who were mobilised by watching their friends and partners die of the disease in the 1980s and 1990s, are left woefully out of touch with the new realities of the disease. For them, HIV will always be the ogre lurking in the shadows, and so any attempt to put it within a wider context of chronic diseases is met with howls about insensitivity or recklessness. They still rely on mobilising outdated fears about the disease to promote safe sex in a way that, for example, diabetes charities never do about eating a healthy diet. By following this old strategy, they inadvertently help to perpetuate the stigma that those with the infection face.
Throughout its brief history, HIV has been both medicalised as a disease and moralised as a stigma. It is the social impact of the condition that now forms the focus after a diagnosis, often far more than the physical aspects. It is the fear of being ostracised that is the biggest problem for those who are newly diagnosed, not the virus itself. Rates of depression in those with HIV are nearly ten times higher than among the general public, in no small part because of the stigma that remains attached to the condition. And if HIV still has status as a scary disease, that’s down to society’s attitude — rather than the virus itself.
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