BRUCE OLMSCHEID, MD:  A pleasure.  Thank you.

CHERYL WILLS:  And also Dr. Brian Boyle is here.  He's an attending physician at New York Presbyterian Hospital, and he's also the assistant professor at Cornell University Medical College.  Thank you.

Of course, now, HIV has become something of a household word.  Let me start with you.  What is HIV?

BRUCE OLMSCHEID, MD:  HIV is a virus that is transmitted through blood and body fluids.  Once someone is exposed and once they're infected, HIV gets into one of the specific cells in the immune system that is responsible for helping the body to fight off infections.  HIV is a very smart, savvy little virus that has learned how to get into a specific cell and destroy that cell, in the process resulting in the patient losing a significant degree of their immune system, so that they lose the ability to fight off infections.

CHERYL WILLS:  Dr. Boyle, when a patient loses that ability to fight infections and they have a weakened immune system, what can happen?

BRIAN A. BOYLE, MD:  It's a spectrum of immunodeficiency that occurs with this disease.  It starts, basically, when the disease first starts.  Many patients have a relatively normal immune system, and then it's only over time that the immune system gets worn out.  The HIV virus is constantly attacking the human immune system.  That attack results in, eventually, the immune system wearing down.  So over time their CD4 count, or what patients call T-cells, tends to fall, and that cell is the quarterback or director of the immune system.  As that cell is lost, the immune system is unable to function normally.  As the patients T-cells or CD4 count falls, the patient becomes more and more at risk for various infections and certain cancers, as well.  We have certain numbers that we use as cutoffs, but when the patient falls below a CD4 count of roughly 200, they become at relatively high risk for infections and some cancers, and that's called AIDS by definition.

CHERYL WILLS:  The viral load is that whole spectrum.  When we hear people talk about their viral load, what are they talking about, exactly?

BRUCE OLMSCHEID, MD:  Well, we used to think that during the 10 years or so between HIV disease and someone developing AIDS that the virus was relatively quiescent, that it really was not very active.  Well, we know now that the virus is very active during that entire time.  The viral load is used as a predictor by us for how rapidly someone might progress to AIDS, depending on what their CD4 count is.  So there have been a bunch of analogies used, but one useful analogy is that it's like a train going down a track and reaching a certain destination, which is AIDS.  The amount of track left is the CD4 count, but the speed of the train is the viral load.  That tells you how quickly someone is likely to progress.  The higher the viral load means that there's more virus, more HIV that's in your body attacking your immune system.  So as you can imagine, Cheryl, that tells you something about how quickly that patient might progress.

CHERYL WILLS:  Sure, sure.

BRIAN A. BOYLE, MD:  Also, I like the analogy of the train.  I use that analogy a lot when I'm discussing this.  But I think another analogy that I've found is very helpful is for people to realize that although I said the virus can get in and can attack and destroy these T-cells, these T-cells have their own amazing ability to regenerate themselves, as well.  But we've learned that it's not unlimited, and if people think of this as the fact that the virus and the T-cells are in this constant battle with each other, I think it's pretty easy to understand that the more virus there is, the sooner the T-cells are going to not be able to -- It's like numbers of people on a battlefield.  So the higher the amount of the virus there is, the sooner the T-cells are going to drop down to a number that's going to make that person at risk for infection.

CHERYL WILLS:  That leads me to my next point.  Initially when this virus was in its early stages, if you had HIV, people just said you had AIDS.  Now we know that this is an epidemic of HIV and AIDS.  Now, what's the cutoff point from having HIV to going to having full-blown AIDS?

BRUCE OLMSCHEID, MD:  That's actually pretty straightforward.  The definition is very clearcut in terms of the actual CD4 count.  Once the CD4 count drops below 200 or -- there's a percentage that goes along with that -- if that percentage drops less than 15%, then that person is no longer defined as simply having HIV but, just by the number, is said to have AIDS rather than just HIV.  I think it's important to throw in and just remind, because people ask me a lot, what's a normal number of T-cells?  I think some people don't remember that.  I just went through that with someone today and reminded someone that a normal number of T-cells is anywhere from 450 to about 1,700.

CHERYL WILLS:  Most people with HIV have a range of what?

BRUCE OLMSCHEID, MD:  It can really vary.

CHERYL WILLS:  Dr. Boyle, what causes a person with HIV to get sick?

BRIAN A. BOYLE, MD:  In addition to having a number cutoff for the definition of AIDS, there are also various illnesses that, if the patient gets those illnesses, those are what called AIDS-defining illnesses.  For example, Pneumocystis carinii pneumonia, which is known by most patients as PCP, is a pneumonia that can tend to occur at less than 200 T-cells.  Because of that, we start patients on prophylactic medications in an effort to prevent that.  But Pneumocystis pneumonia used to be the number one killer and what most patients presented with when they were diagnosed with HIV.  Now, because of the effectiveness of prophylaxis, we can pretty much prevent that.  Many patients are being diagnosed earlier, so they're not coming into the hospital with very low T-cells and Pneumocystis as their diagnosis.  But in addition to that, Cheryl, there are many, many diseases -- toxoplasmosis, cryptococcus -- a number of different organisms -- Mycobacterium avium complex, also known as MAC -- the list goes on and on of different organisms that, when your immune system becomes compromised or it doesn't work very well, that the patient becomes susceptible to.  The other things that commonly cause problems in our patients are things such as cancers that, again, our immune system, not too surprisingly, is also involved in preventing some cancers.  Now we know that such things as cervical cancers and Kaposi's sarcoma and some lymphomas are certainly things that can make our patients sick as well, and those tend to occur, again, when the patient's T-cells are lower, as well.  To answer your question in short order, it's a combination of various infections that they become susceptible to as well as certain cancers which are opportunistic by nature, as well.

BRUCE OLMSCHEID, MD:  I might point out, if I could, that that's very true, but I think it's important also to remember that the way people get sick is that they're not being exposed to these infections.  These are infections that we all have in us.  We've all been exposed --

CHERYL WILLS:  That we can normally fight.

BRUCE OLMSCHEID, MD:  We have all been exposed to many of these organisms throughout, and our body has maintained.  We don't even know we have them, we don't even know that they're in us.

CHERYL WILLS:  Because our immunity can fight them off.

BRUCE OLMSCHEID, MD:  But as the T-cell count drops down and gets below 200 and then below 100 and below 50, you become increasingly susceptible to these infections activating or becoming present in your body because the immune system can't keep them at bay.

CHERYL WILLS:  So does everyone with HIV get sick?  Is that the natural course, or are there some people who can live with HIV and just have a very normal life?

BRUCE OLMSCHEID, MD:  We've actually had the opportunity now, as this disease and infection has been around for -- we've known this for about two decades.  That means we're getting old, doesn't it?  We know that there are what we are calling long-term non-progressors, people who have been exposed to HIV and -- without getting into too much of some of the other scientific details about what we know -- some people are exposed to HIV -- they show up as HIV positive because the antibody test is positive -- but they don't lose their T-cells.  They for some reason are able to maintain their T-cells.  Now, many of them have very low levels of the virus.  You asked about the viral load test before.  We're able to measure not only the T-cells in blood, but we're able to measure the viral load, the HIV viral load, the amount of virus that's there, and for many patients who are long-term non-progressers, their body has somehow established an equilibrium with the virus.  They have a very low level of the virus, and they don't progress.

BRIAN A. BOYLE, MD:  And another category of patient, who 10 years ago we didn't have but we have now, are the patients who are on therapy, and antiretroviral therapy has now -- Does every patient need to get sick?  The answer to that is probably no.  Many of the problems with HIV can be stopped in their tracks by effective use of antiretroviral therapy.  So many of my patients, who probably would have progressed over the past five, six, seven years to AIDS have not because they have been taking antiretrovirals, and their T-cells have, in most cases, stayed actually within normal ranges and their viral loads have been suppressed to undetectable.  Much as you would put a patient into remission if they had cancer, the HIV can be put into remission by using antiretroviral therapy.

CHERYL WILLS:  Let's move on to how one contracts HIV.  There are a number of ways.  Let me start with you.  What's the most common method of transmission?

BRUCE OLMSCHEID, MD:  The two most common methods of transmission are through blood or body fluids.  We mentioned from sharing needles or needle-stick injuries, needle-stick exposures in the hospital, but the most common is sexual exposure, where the virus is in vaginal fluid and in the semen, and just with the exchange of these body fluids, the virus is transmitted from one person to another.

CHERYL WILLS:  Sure, doctor.  And everyone is at risk.  There is no one who has a special immunity.

BRUCE OLMSCHEID, MD:  That's very true, yes.

CHERYL WILLS:  Some people with risky behavior, you would think they had a super-immunity, but really everyone is at risk.

BRIAN A. BOYLE, MD:  I have some patients who have only had one sexual partner, and I think what you need to remember, and what people need to remember, is when they sleep with one person they're sleeping with everyone that other person has every slept with.  So, yes, it's unfortunate, but even with a one-time sexual encounter, HIV can be transmitted.  Now, that's unusual, but it's certainly possible.

CHERYL WILLS:  What are the best methods to prevent transmission?  Safe sex, I assume?

BRUCE OLMSCHEID, MD:  We prefer to really use the words "safer sex" rather than "safe sex," but it certainly is the use of condoms to prevent exchange of fluid.

CHERYL WILLS:  And no drug use, IV drug users?

BRIAN A. BOYLE, MD:  Yes, IV drugs users need to -- I think some needle exchange programs have actually been very, very effective at preventing the spread.

BRUCE OLMSCHEID, MD:  They're controversial, but very effective at reducing the spread.

CHERYL WILLS:  Post-exposure prophylaxis, what do you think about that program?  That, too, is controversial.

BRUCE OLMSCHEID, MD:  It's very difficult.  We're involved in post-exposure prophylaxis.  There are a number of different programs and trials around the country and in the city.

CHERYL WILLS:  And have been for a long time.  It's not an entirely new concept.

BRUCE OLMSCHEID, MD:  There are a number of different points.  I think one of the first points I would really like to be sure that people are aware of with this idea of post-exposure prophylaxis -- Let's define it first.  What we're saying is, the idea of saying, "Well, someone did something that put them at risk," the idea, the hope, the thought that perhaps we could get one of these highly active combinations of drugs into the system as soon as possible -- within two hours, within eight hours, certainly within 72 hours.

CHERYL WILLS:  That's the magic number, 72.

BRUCE OLMSCHEID, MD:  But this is not a morning-after pill.  This is not a morning after pill, and it's very difficult to do studies that are actually going to really show us whether it's effective or not, because it's hard to know what the outcome would have been had they not.

CHERYL WILLS:  Sure.  And we don't know for sure that they actually were exposed.

BRUCE OLMSCHEID, MD:  Exactly.  But the idea here, there is very good data looking at needle-stick exposures, needle-stick transmissions in health care workers, where it's very easy to identify the source patient and know whether that blood, the needle stick, was from a positive patient or not.  What we clearly have shown in that population, if people start one of these regimens certainly within the 72 hours window, ideally within 24 hours, that it appears that we can significantly reduce the risk of that person becoming exposed.  Anything to add on to that?

BRIAN A. BOYLE, MD:  One of the problems is that it kind of goes back to an ounce of prevention is worth a pound of cure, because you have to take these medications for about four weeks, and they're not easy medications to take.  Many, many patients don't tolerate them, and I've seen some studies where the ability of patients to finish a four-week course of these medications is roughly 50% are able to do it.  So it's a very difficult course to take for four weeks, so if you want to weigh the difficulty of preventing it by using, say, safer sex or doing other things to avoid it, it's certainly much more effective and much easier than having to go through this four weeks of difficult and hard-to-take therapy.

CHERYL WILLS:  Let's touch on the myths.  Can you contract HIV by handshakes?

BRIAN A. BOYLE, MD:  No.

CHERYL WILLS:  Kissing?

BRIAN A. BOYLE, MD:  No.

CHERYL WILLS:  A lot of people think you can.  How do we as health professionals better educate people to know that you can't kiss someone and contract HIV, you can't get it from a handshake?

BRIAN A. BOYLE, MD:  I think one of the things we do commonly is, we talk with families of our patients, because they're the ones who are most concerned, and I think justifiably so.  They want information.  So I spend a lot of time sitting down with my patients and their families and telling them about what the risk factors are and aren't so that they feel comfortable at home eating off the same plate and sharing a fork and drinking out of the same glass, because I think there's nothing worse for HIV patients, with all the other things they have to go through, than to have to be stigmatized in their own home.

CHERYL WILLS:  What about oral sex?

BRUCE OLMSCHEID, MD:  I knew you were going to ask that.

CHERYL WILLS:  That's a very, very common concern among some people.

BRUCE OLMSCHEID, MD:  I'm going to take the easy side and let Dr. Boyle talk about the data that was just presented.  It is the one gray area that really, really creates confusion and anxiety for patients.  As I'm doing HIV testing and counseling and working with patients over the long term now to have them adhering to safer sex measures, many of them are having unprotected oral sex.  Let's face it, no one's going to use a condom for oral sex.  People just don't want to do it.  So people are having a lot of unprotected oral sex.  We really try to speak to them about not exchanging fluids, if I can say that and talk about that.  But it's a gray area.

CHERYL WILLS:  So you can contract HIV through -- Can you or can't you?

BRIAN A. BOYLE, MD:  You certainly can, and not only through the semen, but pre-ejaculate also contains HIV, so some people practice withdrawal before they actually ejaculate, but that is not necessarily protective.  There were some studies presented, one in Geneva at the International AIDS Conference and one at Retrovirus a couple of months ago that show that the incidence of infection among patients newly being diagnosed with only oral sex as a risk factor was about 6%.

BRUCE OLMSCHEID, MD:  The only risk factor that they would admit to.

BRIAN A. BOYLE, MD:  Well, some of these studies, Bruce that went back through and asked their partners and looked for other reasons why they might have gotten it, and the only one they could actually find -- I agree, it's not foolproof -- but they looked pretty hard, at least in the San Francisco study to try to find other factors, and then they excluded those people if they could.  I think the one thing we clearly agree upon -- and I think we pretty much agree, in toto -- is that the risk is very, very low, and it cumulatively may add up to somebody getting infected, but the risk of each individual encounter is certainly lower than vaginal intercourse or anal intercourse or anything of that nature.  But can you get it?  The answer is yes.

BRUCE OLMSCHEID, MD:  When I talk with people and counsel people about it, I really try to make sure that they understand that if they're going to engage in unprotected oral sex to really practice the withdrawal method, like you talked about, and that they really have to realize that they're accepting some very low risk that I can't put a number on for them.  It's a very low risk and if we do this over 10 years with multiple partners, is there a possibility that one time they come in the test will be positive?  The answer has to be yes, there is a possibility.

CHERYL WILLS:  Let's move on quickly to testing.  What does testing for HIV entail?

BRUCE OLMSCHEID, MD:  Testing involves simply the use of a blood test that looks for an antibody that is produced in response to the virus being present.  There are two different forms of the test.  There's an ELISA test that, if that is positive, the blood will then be subjected to a more specific confirmatory type of test called the Western blot test, and that will tell whether the patient's been exposed or not.

CHERYL WILLS:  Dr. Boyle, this can be anonymous, right?

BRIAN A. BOYLE, MD:  Yes.  I think that's a very important point.  There's now an FDA-approved test that can be done at home, and there is also a possibility of someone going to some clinics that offer completely anonymous testing where they're identified by number, not by name.  I certainly understand people being afraid of being diagnosed with HIV.  There's still a stigma in our society, although I think there should not, and it bears a lot of implications as far as insurance issues and employment issues and family issues and other things.  But it's very important that they get tested and that they get a diagnosis, especially today, because there are many, many treatments available.  One way that they can do this if they're hesitant to go to their doctor and have it done or to go to someplace where they may be identified is to go get anonymous testing or to get one of these home access kits and do it from the privacy of their own home.