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Friday, April 28, 2017

When to Start HIV Meds?

Written by  Dr. Eva Hersh, MD

Dear Dr. Eva,

My 16-year-old son recently learned he has HIV (not as bad as AIDS). The whole family is upset and trying to decide what’s best for him. It’s my understanding that it’s best to start HIV meds as soon as the virus is found, to protect the person’s ability to fight infections (the immune system). My son says he can’t take medicine every day and that it would remind him every day that he has the infection. Also he may just not be responsible enough – he often misses school and I know he uses some kind of drugs. What do you think?

Worried Dad

Dear Dad,

Your son’s situation is frightening and tragic. Thank you for sticking with him and trying to support him. Unfortunately, many families reject family members who have been diagnosed with HIV.

Your trying to figure out the best health care choices for your son is what any concerned parent would do, but it is very important to understand that decisions about your son’s health care can only be made by him. Even though he is under 18, if you make decisions for him that he does not agree with, you will not be able to make him follow the plan. This would be a problem with any kind of medicine, but it is a deadly serious problem with HIV medicine because of HIV resistance. HIV resistance happens when a person takes HIV medicine irregularly, on-and-off rather than every day. The virus becomes resistant to the medication and the medicine is no longer effective against the virus. In some cases, the virus becomes so medication resistant that no medication will work to treat it.

If your son has been honest with his HIV physician or nurse practitioner about his unwillingness to take medicine every day, his unpredictable lifestyle, and his drug use, his provider should not be pushing him to start on medicines right now. Instead, he needs to stop using drugs, get counseling from an HIV educator to help him cope with the diagnosis, and practice taking a vitamin pill daily to get into the habit of daily medication. These changes will take at least a few months.

Let’s adjust your statement to say that every patient with HIV who is able to handle taking medicine every single day should start on medications as soon as possible after being diagnosed. Those who are not able to do so should work seriously on getting ready.


What to do about my careless HIV positive roommate?

Dear Dr. Eva,

My roommate R and I are both HIV positive. We see the same doctor. My roommate is a player, and he doesn’t tell his partners he is positive. I asked our doctor if he would talk with R’s partners if I got him contact information. The doctor said he can’t because it’s against the law. Well, I know psychiatrists are supposed to contact anyone their patient is threatening. If that is legal, why isn’t it legal to warn people who might get a deadly infection?

Concerned

Dear Concerned,

First, I am not a lawyer. I will answer this as well as I can from the perspective of medical ethics and laws affecting medical professionals.

Medical laws and ethics put great importance on confidentiality of patients’ medical information. That includes test results, treatment, and anything the patient tells a medical professional. Medical information cannot be given to anyone – including the patient’s husband, wife, or family members – unless the patient agrees.

The exception for psychiatrists comes from a less medically complicated era. Passing on an infection was not thought of as threatening someone in the same way as committing murder. We now realize that both could have the same result, but it is much harder to tell if the infected person had the intention of harming their partner. Also, if the partner becomes infected, HIV is now a treatable disease.

Another issue is that, if people with HIV knew their medical information might be shared, it might make them unwilling to get medical care. If that happened, increasing numbers of untreated people with HIV would worsen the epidemic.

A key point is that these laws and ethics do not apply to people who are not medical professionals. If you feel it’s the right thing to do and would not put you in any danger, it would not be illegal for you to inform people at risk.

Have you talked to R? What are his thoughts and ideas? Does he know that if he can get his viral load undetectable, the chance of his infecting partners will be very low? Does he use condoms – and if not, is he willing to rethink that? I don’t know if you will be able to change his point of view, but talking directly to him is your best and potentially most effective step, and does not raise the difficult issues of confidentiality that talking to his partners would.

Eva Hersh is a Baltimore family physician. Send your comments and questions to her by email at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

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