Scott Webb (Host): Though HIV and AIDS have been bumped from the headlines due to COVID-19 over the past couple of years, the AIDS virus is still very much alive. And my guest today wants us to know that between the testing and preventative and treatment medications that are available now, people can live long, happy, healthy lives if they can track HIV. And I'm joined today by Dr. Natali Silva. She's a Family Medicine physician at Salinas Valley Health PrimeCare and hospitalist at Salinas Valley Health, and she was born and raised in Salinas.

 This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb. Doctor, it's so nice to have you here today. We're going to talk about HIV and AIDS prevention, treatment, testing. And I was sort of saying before we got rolling that we don't seem to talk about this much, and I think we still need to. So, I'm glad that we are. So, let's start maybe with the most obvious question. What is HIV? How does someone contract it? And then also, what is AIDS?

Dr. Natali Silva: Yes, that's a good question. So, HIV is a virus that causes the HIV disease and it pretty much turns all your good defense cells into bad viruses and then it can weaken the immune system, making it difficult to fight off any other typical infections or more harmful infections. And then, later on, it progresses to a later stage when your whole body is pretty much depleted of all those good white blood cells and that's when you get the AIDS syndrome or the acquired immunodeficiency syndrome.

Host: Right. So, it starts out as HIV and then can become AIDS. And just generally speaking, what does HIV do to the body?

Dr. Natali Silva: Yeah. So, HIV typically just hijacks all the good cells and then, pretty much, it tricks all the good cells to reproduce all this bad virus. And then, it attacks all the white blood cells and it pretty much prevents your body from fighting off any infections. So, you get all these symptoms and, therefore, not feeling well and then that's how we know when you have HIV.

Host: Sure. Now, doctor, I'm not sure that you're old enough, but I definitely am, sadly. So, I remember the '80s, right? And I remember there was a tremendous amount of stigma in the '80s when people were first diagnosed with the virus. You know, famous folks, Freddie Mercury from Queen and Magic Johnson, the basketball player. But, as I was saying, you kind of hardly hear about it now. Just wondering ,where are we at in terms of the stigma?

Dr. Natali Silva: Yeah. I believe like there's a lot of layers to this question. I feel like there's still a lot of stigma, especially in our community. Like you mentioned in the intro, it's not heard of anymore. And that's because, you know, we've got great progress, we have medications, and we have preventive medications that we didn't have before. And before, people got scared and it was like a hot topic for that reason. But nowadays, we have more treatment, but people are still shying away from it, because they still have the stigma that people who are homosexuals, typically those are the higher risk, but it's not true. Everybody is a higher risk who engages in risky sexual behavior. But unfortunately, people are afraid to discuss this, like being open about their sexuality to their doctors. So, therefore, people are not getting tested and then, we don't know if they have HIV or not.

Host: Right. And I wanted to follow up and, you know, it seems like an HIV diagnosis is not the death sentence that it once was. But that's for folks who may be engaging in risky behaviors, but they're also being tested. They may be, you know, taking the preventative medicines and things like that, right? So, folks don't have to die from HIV anymore, right?

Dr. Natali Silva: Totally. You're totally right on that. So, it's really nice to see that. I think people in the '80s would have loved to have that. And I think, you know, people take it for granted. Just because we have all these things, it doesn't mean that you cannot get infected and that's the problem. We need people to talk to their providers and be like, "Can I get tested? Can I get STD testing?" Because for that same reason, HIV is not a death sentence anymore. We have a new term. It's called U equals U, meaning undetectable is untransmissible, which is mind-blowing. We've never had this before. So, people can actually be HIV-positive and still be okay and live a long term. And even in comparison to other diseases like diabetes, You could have more complications with that than just a HIV diagnosis. So, we've come a long way.

Host: Right. Yeah. I'm not a doctor and so this is purely anecdotal, but it feels like, unfortunately, far more people died of COVID in the last few years than have probably died from HIV and AIDS. Does that sound right? Does that check out?

Dr. Natali Silva: Yes. The pandemic for COVID really blew us out. We had no idea how to manage it and we started learning. But unfortunately, it was a really strong virus and a lot of people ended up passing away. So, it was kind of like similar what happened with HIV in the beginning. We had no idea, now it got studied, and now we have all these medications. So, yes, it's similar to that. That's the reason why we try to prevent getting HIV with preventative medication or testing so that we don't have the same thing of like another HIV pandemic.

Host: Right. Yeah. And just wondering about Monterey County, what's your sense of things? What are the numbers telling you? Is there an increase in infections? And maybe you could sort of compare and contrast that with the entire country.

Dr. Natali Silva: Yeah. So, unfortunately, you know, COVID-19 really hit us really hard in all aspects. I guess you guys can remember, we were in curfew, so data was not really collected. And unfortunately, like you said, it was a big pandemic and people were dying mainly from COVID. So, we have no really good data of how many HIV infections were in the county, but we do have for the U.S. Back in 2021, there was about 36,000 new cases of HIV, which is a lot. But, you know, we shouldn't be having that many, given that we have all these new preventative medications. And people who are HIV-positive should be able to get HIV medication like antiretrovirals and prevent infection. So, there are still some cases that are still happening. But, you know, COVID-19 really hit us hard in all aspects of our lives, and also to quantify how many new HIV cases are happening.

Host: Sure. So, let's talk about the transmission of HIV and how do we prevent it. Let's also go through testing. You know, how is the testing done? How often should people be tested? And also, do you do HIV testing at PrimeCare?

Dr. Natali Silva: Transmission, HIV is preventable. So, the transmission, there's a couple ways. If you engage in high-risk sexual activity and without condoms, you're high risk. If you have sexually transmitted diseases such as chlamydia, gonorrhea, that kind of puts you at harm to even higher risk of HIV. And then, unfortunately, you know, there's another case where people share like needles and they're doing drugs and they're exposed to HIV. Or pregnancy, you know, like if someone's pregnant with HIV status and they're not taking medication, unfortunately, their baby will also get infected. So, that's something that we can't really prevent if the mother doesn't go and seek help. So, that's the reason why we have to get tested and make sure we follow with our doctors.

And there are many testing that we can do. And it's pretty much the antibody test, and then we do a blood test. There's also some testing that is the same day, it's a rapid test. Various clinics can provide this testing. PrimeCare does, and all our local clinics in the Monterey County have all these, testing available, even like Planned Parenthood. It's just the actual patient needs to be okay with it. So, first of all, it's a discussion with the primary provider and also consent, right? Because if they don't want to get tested-- you know, this happened before. I've opened this with a lot of my patients and a lot of them have declined.

Host: Yeah. And, you know, maybe that's a separate podcast. We touched on a little bit about the stigma part of it. And, you know, testing is so open and available, and it does make you wonder why folks would decline. But we're not here to judge, of course. We just want them to know that testing is available just about everywhere they could think of, and as is the treatment. So, let's talk about that. Let's talk about the treatment, what HIV PrEP is, and so forth.

Dr. Natali Silva: There's no cure for HIV. But basically, there's treatment that can help you live a good lifestyle. So, these are antiretrovirals. They're a little bit more complicated. You have to go through a doctor or infectious diseases doctor. But typically, people who get these medications, they need to make sure that they are committing to taking these medications on a single day basis because, you know, the virus is really smart. And if you skip certain doses and you start skipping, it doesn't guarantee that you cannot get the virus spreading into your body. So, that's one of the reasons why you have to be really faithful and take your medications and keep making sure you go to the doctor and check the levels.

But there's other medications, which is called pre-exposure prophylaxis. And there's also post-exposure prophylaxis So, PrEP is pretty much like similar medications that people who are HIV-positive, but not the whole complete treatment. And you pretty much take it every single day. But again, you are at high risk if you engage in high-risk sex activity. And if you have a chlamydia, gonorrhea, that places you at higher risk, so you have to go to the doctor and get testing since you're taking that PrEP. And hopefully, you know, you don't contract any chlamydia or gonorrhea. And if you do, you get treatment for that. And you still continue that on a daily basis. And now, you don't have to take oral. There's also like an injectable now, which we never thought we were going to have. So, that's pretty cool, because it's every two months or so. And you can just ask your provider to see if you could have those options either oral or injectable preventative medication.

Host: Yeah. It's nice to hear just how far we've come since the '80s when this first hit, you know, here and abroad, but also just trying to remove some of the barriers, right? Some of the objections, if you will. "I don't want to take a pill. I don't want to take multiple pills per day." And as you say, now for some people anyway, the right patients, there's injectables. You touched on this a little bit earlier. Is it safe to have sex with someone who is HIV-positive or maybe has developed AIDS?

Dr. Natali Silva: Yes and no. So basically, if somebody is HIV-positive and doesn't take their medications, your virus is still replicating, so you're a higher risk if you engage with any person with sexual activity. But if you are HIV-positive and you're taking your medications and your virus is so low, it's basically undetectable, you could have sexual activity with your partner, even though they're like not HIV-positive and still have a minimal risk of infection, but that's only those people that are being really well-controlled with their medication and they go to their doctor and they know their levels, their viral level. Those are the people that you're okay with having sexual activity without really having the high risk of infection.

Host: Sure. Yeah. So, let's move on to the symptoms of HIV, and we've touched a little bit on COVID today, and this is not a COVID podcast, but, you know, virus nonetheless. One of the issues with COVID, of course, is that symptoms mirrored so many other things, you know, whatever it was, runny nose, cough, congestion, those kinds of things. So, how does someone know, I guess? Would they know if they had HIV? Or is it just they don't feel well, and it's time to speak with the doctor and find out what's going on?

Dr. Natali Silva: Yeah. Thank you. You summarized it pretty well. Unfortunately, that's the truth. In the acute phase, that's really how you feel, like you don't feel good, you have almost like an upper respiratory infection, like fevers, cough, simple things that you could think like, "Oh, it's just simple." But then, you know, your body was able to fight it well, But as the virus gets into your body, your system gets weaker, and that's when you start getting all these different infections that typically normal people will fight it off. And most of the common ones are like fungal, or like, let's say you're really young, like in your 20s, and you have a pneumonia, which is not a common infection to have when you're young. So then, that kind of triggers a warning for any provider, like, "Hey, what's going on?" And you talk about your, you know, sexual activity, and then that's when you want to do testing. You need to have a good rapport with your patient, because at the end of the day, if the patient declines, we can't get tested. But typically, the people who get infected are really the ones that take a while to get seen. And then, they go to the hospital when they're really sick. And unfortunately, that's how we figure out they're positive most of the time.

Host: And, doctor, wondering, can a woman who's HIV-positive pass the virus to their baby during pregnancy?

Dr. Natali Silva: So yes, actually you can transmit. So if a mother is pregnant, you would want for her to take medications during pregnancy. And in order to prevent transmission during the delivery, because that's when all the fluids can kind of get more into contact with the baby. They typically want to do C-section and the baby actually needs some HIV medications after birth. But still, there's a high risk because it's a nine-month pregnancy, and the baby is a higher risk because if the mother is not controlled with their viral load, it's just a higher risk of actually the baby contracting HIV.

Host: Gotcha. And you mentioned earlier that there is no cure per se for HIV, that folks can live long, happy, healthy lives, normal, if you will. But there's no cure. Do you envision there ever really being a cure for HIV? for Or at this point, is this probably as good as it's going to get? And there'll just be some improvements in terms of how, like, let's say PrEP or, you know, those types of things are delivered?

Dr. Natali Silva: I think I'm kind of hopeful that things can turn into a good. You know, that could be something that could be done and then it's curable, because we've come a long way. I mean, who ever knew that we were going to have injectables and people were going to live? Because back in the '80s people were dying, like a lot of people were just dying quickly. So now, to see all these patients living up to a healthy 80-year-old and still being pretty good, I'm pretty happy with that. And I think this is already a good progress. People are living a good life with just taking oral medications and now injectables like every two months, so that's preventive. Unfortunately, for people who are HIV-positive, they really do have to take oral medications every single day. But I mean, they're living a good quality of life. I feel like that's a great progress. So, I'm hopeful that we can find a cure.

Host: Yeah, for sure. As you say, it's been around a long time and we know so much more, we've come so far. But why not have a cure, you know, if possible, but folks are living longer, happy, healthy lives, which is great to hear. I hate to be a bummer here, but if a person knows that they're HIV-positive, do they have a legal duty to share that information with their partners? And are there any ramifications if they don't and their partners end up getting HIV?

Dr. Natali Silva: Yeah. So, I want to distinguish this question because some people think like, "Oh, if I get tested people are going to know my status or they're going to know that I tested." Well, that's not true. We have laws, you know, HIPAA that we can't really disclose this information. So just because you get tested, it doesn't mean that is shared to anybody that's just confidential between you and your doctor. But when we do have a positive HIV test, we do have to contact that patient. Obviously, we have to connect them to all the clinics. We have a lot of programs here like the Needle Clinic. It's run with the help of Dr. Radner who is also Salinas Valley Health who's an Infectious Diseases doctor. And we have access to network. And then, we have, you know, our local PrimeCare clinics and other clinics in Monterey. So, we can help them with their treatment and management. But unfortunately, it is infectious diseases like HIV. So, we have to report it to the county. And these people do need to be contacted and figure out who they've been sexually active with. And those people need to be contacted legally so that they can get either checked and, you know, possibly get treated. Because sometimes, like I told you, in the acute phase, you don't feel anything, but then you start getting more into the virus and then people start feeling bad. So, it is a crime if you don't contact those people that were exposed in California. But there are some states that might not have that as a crime, but California is you need to notify your partner.

Host: Sure. I'd just give you a chance here at the end. Final thoughts, takeaways in framing here HIV, AIDS, prevention, treatment, testing. What are your final thoughts?

Dr. Natali Silva: Yeah. My final thoughts is just like making sure people feel comfortable to talk about their sexuality with their doctors, like who else is going to listen to you than your doctor. And also, making sure that, you know, you have your own autonomy, you have to go to your primary and get testing if you are concerned, because that's the way we know how to prevent and how to guide you.

But if you're not open enough, we can't really do any testing. So, I just want to encourage for patients to be, a little bit more comfortable and talking to their provider and seeing like what they can do, like STD testing, HIV testing. And hopefully, we can help them more and minimize the stigma, especially in our community.

I feel like people still think people who are engaging with sexual activity with men and men, pretty much they're a higher risk, but that's not true. Everybody is a higher risk. And basically, the guidelines say at least once in your lifetime, you should get tested for HIV. And I hope that patients don't feel a certain type of way when doctors try to open up the question about STD testing. We're not telling you guys that you're engaging in different behaviors or not. We're not trying to judge. We're just trying to do like the actual thing of screening, at least once in your lifetime. And then, just opening that up can kind of be helpful for other patients to be comfortable and being like, "Okay, let's get tested." but that's kind of what I want, like more preventative.

Host: Yeah. As you say, there's no judging. It's just about saving lives, right? And that's what medical professionals do, of course. So, I really appreciate your time today. Thanks so much.

Dr. Natali Silva: Thank you so much. I appreciate it.

Host: Please get tested. Dr. Natali Silva is a Family Medicine physician accepting new patients at Salinas Valley Health PrimeCare. To make an appointment, call 831-759-3257. And to listen to more of our podcasts, please visit salinasvalleyhealth.com/podcasts. And if you found this podcast to be helpful, please be sure to tell a friend, neighbor or family member. And subscribe, rate and review this podcast, and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well, and we'll talk again next time.