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Editor,—A 33 year old homosexual white male attended an HIV outpatient clinic as an urgent case. He was a healthcare worker involved at a senior level in the care of HIV positive clients and had himself received an HIV diagnosis in 1994. Antiretroviral therapy had commenced in 1998 with a combination of didanosine, stavudine, and nevirapine. This was well tolerated and brought about rapid and sustained viral suppression and a significant increase in CD4 count. The client had been an irregular attender and had often collected repeat prescriptions without medical review. Significantly, no details of his sexual history were recorded for the 6 years following diagnosis, although the existence of a partner was acknowledged in the month before his acute presentation.
He attended with a 2 week history of fever in the absence of any other symptoms. On examination he was pyrexial with a temperature of 38.8°C. A 1 cm raised nodule on the centre of the dorsum of the tongue was noted. There was no apparent regional lymphadenopathy.
Requests for viral and bacterial culture were made and blood was sent for syphilis serology. In order to exclude a neoplastic lesion an urgent referral was made to an otolaryngologist for biopsy. At this stage he reported that his only recent sexual activity had been with his longstanding partner.
Two weeks after his initial presentation he reattended for review. The previously noted nodule had become ulcerated yet remained painless and firm to palpation (fig 1). TPPA, FTA IgG, and FTA IgM measured at the time of initial presentation were found to be positive with a reactive VDRL at a 1:32 dilution. A diagnosis was therefore made of primary syphilis with a chancre of the tongue. The client opted for treatment with doxycycline 100 mg three times daily for 3 weeks. On further questioning he revealed that he had engaged in unprotected anal and oral sex with his regular partner (who had recently tested HIV antibody negative) but had also had oral sex with a casual male partner approximately 3 months before his acute presentation. This casual contact was untraceable. However, the client's regular partner attended for assessment. He was found to have oropharngeal ulceration and strongly positive syphilis serology consistent with primary syphilis.
We believe that this case highlights some of the important issues faced by people living with HIV in this decade. How is it that an informed and intelligent individual who has professional experience of HIV puts himself and others at risk in this way? Since the early days of the epidemic a cornerstone of HIV management has been a process of education and empowerment to enable the people living with HIV to minimise the risk of acquiring a sexually transmitted infection or transmitting HIV infection to his or her partners. The huge changes in sexual behaviour seen in the 1980s and 1990s among homosexual men were unprecedented and frequently brought about by gay men's groups in the face of government indifference or inaction. A standard was set for HIV control for other communities to follow.
There is good evidence of increased participation in unsafe sex among homosexual men in the United Kingdom1 and other Western societies. The availability of effective anti-HIV treatment has possibly promoted this.2 A process of “safer sex fatigue” has set in; our clients are bored with hearing this mantra and we are bored with chanting it. As the relationship between HIVpositive people and their physicians develops communication is often made more, rather than less, difficult. We are embarrassed to raise the issue of sex as we do not wish to appear to be in judgment on our patients. Our patients do not want to disappoint us by telling us that they have had unsafe sex. The internet has developed as a new forum for sexual mixing and has been cited as a factor in sexually transmitted infection clusters. Partner notification in these circumstances is fraught with difficulties.3
The success of antiretroviral therapy has allowed people living with HIV to face the future with more optimism and to plan for productive lives, careers, relationships, and families. This has gone some way to undermining the safer sex message. Marketing of antiretrovirals by pharmaceutical companies consistently portrays an image of health and robustness. The subtext appears to be that HIV is a minor inconvenience that is barely worth avoiding. Against this backdrop looms the threat of primary antiretroviral resistance. Recent work has described viral resistance patterns in primary HIV infection that could represent significant handicaps to its effective long term treatment. In recently acquired HIV infection diagnosed in the United Kingdom in 2000, 27% of cases possessed such mutations.4
Risk taking in the context of sexual experience defies neat scientific description and is highly situational. In the case we described here our client was utilising unprotected oral sex as a personalised means of risk reduction. Most homosexual men rely on their life experience and instincts to help them make decisions about the sexual risks that they take. Occasionally this process will let them down. To give them the best possible information on which to base their choices is likely to be the best that we can hope to do.
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