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How HIV Still Surprises Us

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StellaFitzgibbon, MD

 

by Stella Fitzgibbons, MD

You would think that doctors would feel pretty cocky by now about HIV. We can test for the virus and tell you how much of it there is and what it’s done to the immune system, we have a slew of drugs to control it, and we can treat the cancers and most of the infections. But the little SOB still has effects we don’t understand, so it can still blindside us sometimes.

Lose the guilt trip
Even the most dedicated activist can occasionally be derailed by the thought of how many childhood diseases we could prevent for the price of developing one anti-HIV drug. Well, stifle that: HIV research isn’t just for HIV.

When I was in med school, immunology was a simple little one-quarter course. We knew there were several types of white blood cells and that some of them produced antibodies and others ate bacteria and rejected foreign tissue. Boy, is it complicated now: the “T-cell count” we follow in HIV patients includes just those T cells with the CD4 cellular marker, and we know of dozens more markers that identify other subsets. And all sorts of white cells produce substances called cytokines that regulate functions from killing tumor cells to making the body grow new blood vessels.

And it’s not even an infection
One of my saddest cases involved a guy who had elective surgery for an orthopedic problem. The operation went as planned and he started the follow-up treatments…but somehow the bones wouldn’t heal right. I mentioned the problem to Seema Shah, my favorite infectious disease specialist, who asked if the patient was gay. “Impaired wound healing, remember?” said Seema. “Better check the HIV test.” (We still don’t quite understand how HIV does this—probably some effect on the white blood cells involved in tissue repair and scar formation.)

After a few more unpleasant surprises, the surgeons in our group started to make an HIV test a routine part of preoperative testing, and making their incisions as small as possible. When surgery was unavoidable, they used stronger materials that wouldn’t dissolve. Drains got left in longer to be sure they were doing a complete job, and wound care nurses got extra careful.

Moral: if you’re HIV positive, tell your surgeon. And if there’s a specialist in minimally invasive surgery nearby, ask if your operation can be done through a smaller incision.

Another HIV patient came in with a high CD4 count but said she got out of breath climbing stairs. An exercise program and a few pounds of weight loss fixes this 95 percent of the time; she was in the other 5 percent, though, and an echocardiogram showed pulmonary arterial hypertension. This was before we had medications to keep these folks alive longer, and a heart-lung transplant was about all we had to offer. She died suddenly—not uncommon in PAH, but horrible for her family—before the Baylor specialist had finished a full evaluation.

Blood clots are another rude surprise, and they can cause problems from painful swelling of the legs to heart attacks. The coagulation system isn’t even supposed to have anything to do with the immune system, but somehow HIV affects it.

Unexpected good news
Not all the mysteries are bad ones. My favorite is the so-called “long-term nonprogressors.” A small minority of people infected by HIV are able to live for years with normal CD4 counts and low viral loads, and we’re still figuring out why.

Another bright spot that astonished even the average doctor: organ transplants. We have to suppress immunity to prevent rejection of the new organ, and it would seem logical that the HIV infection would take over when the body lost that disease-fighting capacity.

Stella Fitzgibbons, MD, has practiced medicine in Houston since 1981, both in primary care and in hospitals. Her interest in LGBT issues started with a gay brother and continued through the years since HIV appeared.

 

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