http://www.cdc.gov/hiv/prevention/resear ch/art/
What is the Risk of Sexual HIV Transmission for HIV-infected Persons With Undetectable Viral Load?
ART is considered effective when it consistently suppresses plasma viral load to undetectable levels. However, sexual transmission of HIV from an infected partner who was on ART with a repeatedly undetectable plasma viral load has been documented.8 An infected partner's genital (seminal or vaginal) fluid viral load may play a greater role than plasma viral load when evaluating the risk of sexual transmission of HIV. The likelihood of HIV transmission in the setting of ART is influenced by a number of factors, several of which are described below.
The Meaning of “Undetectable” Viral Load: Persistence of Virus in Plasma and Seminal Fluid
Periodic blood plasma viral load monitoring is used to measure ART effectiveness. The goal of effective ART is the long-term suppression of plasma viral load, usually defined as the maintenance of a level of HIV virus that is below the threshold detectable by available tests. While plasma viral load tests are reliable, they have limitations: virus levels below a minimum concentration may not be detected. Studies have shown that persistent virus is found in peripheral blood mononuclear cells9, 10 even when individuals have sustained undetectable plasma viral load levels.
Genital fluid viral loads are not routinely measured in persons on ART. Although ART reduces concentration of virus in seminal fluid,11 virus persists within cells present in seminal fluid of some men who are on ART with undetectable plasma viral load.12-13 ART also is associated with decrease in cervicovaginal fluid viral load; however, ‘breakthrough' shedding has been observed in some studies.14-17 Therefore, the potential for transmission exists despite sustaining undetectable viral load while on effective ART.
Transient Increases (“Blips”) in Viral Load
Several studies have observed that individuals on effective ART who achieve long-term suppression of viral load to undetectable levels may exhibit periodic temporary increases in plasma viral load (blips). These are generally small increases ( between approximately 50 and 1000 copies/mL), and are estimated to last for short periods (<3 and="" are="" be="" because="" blips.="" conceivable="" correlate="" currently="" data="" enhanced="" fluid="" genital="" however="" in="" increases="" insufficient="" is="" it="" load="" magnitude="" make="" may="" might="" missed="" nature="" of="" on="" regarding="" related="" risk.="" risk="" routine="" sexual="" span="" statements="" testing.="" that="" the="" there="" they="" to="" transient="" transmission="" viral="" weeks="" with="">
Correlation Between Plasma and Genital Fluid Viral Load and Resistance to ART
Although ART reduces viral load in both plasma and seminal fluid, undetectable plasma viral load may not always predict undetectable seminal fluid viral load. A recent review of 19 studies, which compared plasma and seminal fluid viral loads, indicates that while blood and genital fluid viral load are often correlated, this is not always the case.21 Thus, a person with an undetectable plasma viral load may still shed virus in genital fluid at higher levels, which poses risk for transmission.
Several additional factors may affect genital fluid viral load. For example, sexually transmitted infections (STIs) such as gonorrhea and chlamydia have been shown to transiently increase viral load in genital fluids.22-23 Individuals with active STIs may therefore be more infectious, despite a low or undetectable plasma viral load. Moreover, as individuals with STIs may not have any symptoms, it may be impossible for either partner to be aware of this increased risk.
Some of the variation in genital fluid viral load may be due to differences in the degree to which different ART medications enter genital fluid. Recently developed research methods allow for measurement of drug concentrations in seminal and vaginal fluids, which can then be compared to drug levels measured in blood. This research has found that some ART medications achieve higher concentrations in genital fluids than others.24-27 For instance, nucleoside/tide reverse transcriptase inhibitors (NRTIs) penetrate to a greater extent in male and female genital secretions than do protease inhibitors (PIs). Further work of this type may eventually aid in selection of antiretroviral medications in order to reduce sexual transmission. However, more data collected via these methods and better understanding of the degree to which this approach might be effective is needed before specific recommendations can be made.
In addition to differences in viral load between plasma and genital fluids, there may also be differences in the resistance characteristics of virus in these two locations. HIV may become resistant to ART medications through mutations that occur during replication and through exposure to insufficient or inconsistent levels of HIV medications. This may happen when ART medications are not taken according to the prescribed schedule or doses are skipped. In addition, drugs which do not enter the genital fluid as well may help promote the development of resistance in the genital fluid specifically. Some researchers have noted that within an individual, the resistance characteristics of virus isolated from genital fluid may differ from those of virus isolated from plasma.28-30
In summary, for couples in which one member is HIV-infected, treatment of the infected partner with effective ART and suppression of viral load to undetectable levels should greatly reduce the risk of transmission to the uninfected partner. However, this risk is not eliminated and it may not be maximally reduced at all times due to some of the factors discussed above. Moreover, the likelihood of transmission may be expected to increase with repeated exposures over time. In a model which estimated transmission risk in the setting of suppressed viral load (<50 10="" 11="" 215="" 3="" 425="" 5="" 70="" a="" additional="" among="" analysis="" and="" art="" be="" chance="" cohorts="" compatible="" condoms="" copies="" couples="" data="" e.g.="" estimated="" event="" events="" expected="" female-to-male="" for="" from="" further="" heterosexual="" however="" important="" in="" including="" individual="" intercurrent="" is="" it="" load="" male-to-female="" male-to="" male="" meta-analysis="" methods="" minimize="" ml="" no="" number="" observed="" occurring="" of="" one="" order="" over="" per="" person-years.32="" persons="" population="" possibility="" preventive="" reason="" receiving="" recognize="" risk="" serodiscordant="" span="" stis="" that="" the="" this="" to="" transmission.="" transmission="" transmissions.31="" transmissions="" use="" viral="" was="" with="" within="" without="" years="">
Monday, October 28, 2013
A couple of post from articles about transmission risks for men with HIV who have "undetectable" viral loads
" 7th IAS Conference on HIV Pathogenesis, Treatment and Prevention, June 30-July 3, 2013, Kuala Lumpur
Mark Mascolini
In the first study to track HIV shedding in semen over time in men who have sex with men (MSM) with sustained HIV suppression in blood, 7.6% of men with undetectable virus in blood had intermittent shedding in semen that was not linked to an asymptomatic sexually transmitted infection (STI) [1]. HIV levels in peripheral blood mononuclear cells (PBMCs) predicted HIV detection in semen.
Research shows that an undetectable viral load in plasma does not guarantee an undetectable load in semen--and therefore may not eliminate the risk of sexual HIV transmission. But most data on this issue come from cross-sectional studies involving heterosexual men in medically assisted reproductive programs. A French team conducted this study to address these questions in a longitudinal study involving MSM.
The study involved HIV-positive adult MSM on a stable antiretroviral regimen with a plasma viral load below 50 copies for at least 6 months. No men had clinical symptoms of an STI, and all agreed to abstain from sex for 48 hours before giving semen and blood samples. The researchers collected paired semen and blood samples at a baseline visit and 4 weeks later. They also measured PBMC-associated HIV DNA and tested men for syphilis and other STIs. Based on a 3% to 5% rate of genital HIV shedding in heterosexual men, the investigators calculated that they would need 150 men to find at least one blood-semen discordance if prevalence was as low as 3%.
The researchers recruited 153 MSM with a median age of 44 years (range 27 to 67). Median time since HIV diagnosis was 10.4 years, and median nadir and current CD4 counts were 247 and 637. Median PBMC HIV DNA stood at 229 copies per million cells (range 70 to 2099). These men had taken a stable antiretroviral regimen for a median 2.1 years (range 0.3 to 12.4) and had an undetectable viral load for a median 3.3 years (range 0.5 to 13.7). Almost two thirds of men (63%) had a stable partner, though 63% with a stable partner also had casual sex with a median of 10 other men in the past 3 months (range 1 to 160).
HIV could be detected in 23 of 304 semen samples at a median level of 145 copies/mL (range 50 to 1475) to yield a prevalence of 7.6%. Five men (3.2%) had HIV detectable in semen at the baseline visit but not week 4, while 2 (1.3%) had HIV detectable in semen at both visits, and 14 (9.1%) had HIV detectable at week 4 but not the baseline visit. HIV could not be detected in 74% of semen samples by an ultrasensitive assay.
Thirty-two of 157 men (20.4%) had an asymptomatic STI detected, and 2 men had two STIs. Ureaplasma urealyticum was the most frequent STI, affecting 18 men, followed by syphilis in 6, Gardnerella vaginalis in 4, Chlamydia trachomatis is 3, and Neisseria gonorrhoeae in 2.
Multivariate analysis identified two factors associated with detectable HIV in semen: A current CD4 count between 554 and 735, compared with a lower count, cut the odds of HIV in semen 70% (odds ratio 0.3, 95% confidence interval [CI] 0.1 to 0.9, P = 0.027). And HIV DNA in PBMCs above versus below 318 copies per million cells tripled the odds (odds ratio 3.1, 95% CI 1.2 to 7.7, P = 0.015). HIV detection in semen was not associated with STIs, CDC stage, nadir or current CD4 count, duration of undetectable HIV in plasma, adherence to antiretroviral therapy, or number of sex partners.
The researchers noted that seminal HIV prevalence in this study was significantly higher than in a recent cross-sectional study of heterosexual French men (7.6% versus 3.1%, P = 0.016) [2]. Whether these levels of HIV in semen are infectious, they added, remains to be determined. "
1. There is viable HIV in the semen of many men who have "undetectable" viral loads.
2. How big a risk for infection this presents is unknown, but I'd be it's not zero.
Mark Mascolini
In the first study to track HIV shedding in semen over time in men who have sex with men (MSM) with sustained HIV suppression in blood, 7.6% of men with undetectable virus in blood had intermittent shedding in semen that was not linked to an asymptomatic sexually transmitted infection (STI) [1]. HIV levels in peripheral blood mononuclear cells (PBMCs) predicted HIV detection in semen.
Research shows that an undetectable viral load in plasma does not guarantee an undetectable load in semen--and therefore may not eliminate the risk of sexual HIV transmission. But most data on this issue come from cross-sectional studies involving heterosexual men in medically assisted reproductive programs. A French team conducted this study to address these questions in a longitudinal study involving MSM.
The study involved HIV-positive adult MSM on a stable antiretroviral regimen with a plasma viral load below 50 copies for at least 6 months. No men had clinical symptoms of an STI, and all agreed to abstain from sex for 48 hours before giving semen and blood samples. The researchers collected paired semen and blood samples at a baseline visit and 4 weeks later. They also measured PBMC-associated HIV DNA and tested men for syphilis and other STIs. Based on a 3% to 5% rate of genital HIV shedding in heterosexual men, the investigators calculated that they would need 150 men to find at least one blood-semen discordance if prevalence was as low as 3%.
The researchers recruited 153 MSM with a median age of 44 years (range 27 to 67). Median time since HIV diagnosis was 10.4 years, and median nadir and current CD4 counts were 247 and 637. Median PBMC HIV DNA stood at 229 copies per million cells (range 70 to 2099). These men had taken a stable antiretroviral regimen for a median 2.1 years (range 0.3 to 12.4) and had an undetectable viral load for a median 3.3 years (range 0.5 to 13.7). Almost two thirds of men (63%) had a stable partner, though 63% with a stable partner also had casual sex with a median of 10 other men in the past 3 months (range 1 to 160).
HIV could be detected in 23 of 304 semen samples at a median level of 145 copies/mL (range 50 to 1475) to yield a prevalence of 7.6%. Five men (3.2%) had HIV detectable in semen at the baseline visit but not week 4, while 2 (1.3%) had HIV detectable in semen at both visits, and 14 (9.1%) had HIV detectable at week 4 but not the baseline visit. HIV could not be detected in 74% of semen samples by an ultrasensitive assay.
Thirty-two of 157 men (20.4%) had an asymptomatic STI detected, and 2 men had two STIs. Ureaplasma urealyticum was the most frequent STI, affecting 18 men, followed by syphilis in 6, Gardnerella vaginalis in 4, Chlamydia trachomatis is 3, and Neisseria gonorrhoeae in 2.
Multivariate analysis identified two factors associated with detectable HIV in semen: A current CD4 count between 554 and 735, compared with a lower count, cut the odds of HIV in semen 70% (odds ratio 0.3, 95% confidence interval [CI] 0.1 to 0.9, P = 0.027). And HIV DNA in PBMCs above versus below 318 copies per million cells tripled the odds (odds ratio 3.1, 95% CI 1.2 to 7.7, P = 0.015). HIV detection in semen was not associated with STIs, CDC stage, nadir or current CD4 count, duration of undetectable HIV in plasma, adherence to antiretroviral therapy, or number of sex partners.
The researchers noted that seminal HIV prevalence in this study was significantly higher than in a recent cross-sectional study of heterosexual French men (7.6% versus 3.1%, P = 0.016) [2]. Whether these levels of HIV in semen are infectious, they added, remains to be determined. "
1. There is viable HIV in the semen of many men who have "undetectable" viral loads.
2. How big a risk for infection this presents is unknown, but I'd be it's not zero.
Saturday, October 6, 2012
I've been asked recently my thoughts about Qpid.me, a service that notifies authorized users of a member's HIV status.
To some degree, I think these services, and I believe there are several, are already obsolete because of Orasure's home test kits, but this is what I think.
Many men are worried about such aps making stigma worse. I disagree. There is just a certain population of men that is going to act on the abstract fear of winding up like "Philadelphia," and you cannot reach them. The guy who turns and runs from a text would already have turned and run when you just told him, as you were going to do, anyway. It still stings, but Qpid would only alter the timing.
On the other hand, there some essential problems with any text-based ap that attempts to identify people with or without HIV:
Of the estimated 1.2 million HIV infected people in the USA, 240,000, or 20% are unaware of their infection. For gay men in urban areas, the figure is 44%. 16% of these had NEVER been tested. Of recently infected gay men "unaware" of their status, 45% had been tested within Qpid's 12 month window. Dependence on any 12 month old lab result is highly likely to lead to new infections, not to prevent them.
I'm sure the prevalence of texting phones is high in gay men, but it is not universal, and any service that requires testing within 12 months is going to face the same issues that testing itself faces. Fear of a positive result will discourage people from signing up. Positive men have no reason to sign up in the first place, no matter how honest they are about disclosure. If the percentage of users remains small, the value of the service is low, even if the test results given were immediate and accurate. Qpid offers zero protection against those who lie about their status, as they simply won't be subscribers, and given the "low penetration" of the service," someone who uses it is going to find a lower percentage of users than "certified negatives." I simply cannot imagine many men saying, "Since you don't have Qpid, I won't go home with a horny man who looks like a Colt Model." Sexual decisions are, for better or worse, almost never that mathematical.
I suppose it's possible it might encourage a few kind of nerdy and paranoid men to be tested, and that's a good thing. The bottom line is that only safer sexual practices, honest discussion, and education can really help.
In short, I think Qpid cannot deliver reliable laboratory information that increases safety, because it depends on old results in a population with lots of recent infections. I do not believe it could ever reach a percentage of users that would allow it to be of use in the first place…
and I hope they have a team of lawyers specialized in HIPAA issues, because they're going to need it.
To some degree, I think these services, and I believe there are several, are already obsolete because of Orasure's home test kits, but this is what I think.
Many men are worried about such aps making stigma worse. I disagree. There is just a certain population of men that is going to act on the abstract fear of winding up like "Philadelphia," and you cannot reach them. The guy who turns and runs from a text would already have turned and run when you just told him, as you were going to do, anyway. It still stings, but Qpid would only alter the timing.
On the other hand, there some essential problems with any text-based ap that attempts to identify people with or without HIV:
Of the estimated 1.2 million HIV infected people in the USA, 240,000, or 20% are unaware of their infection. For gay men in urban areas, the figure is 44%. 16% of these had NEVER been tested. Of recently infected gay men "unaware" of their status, 45% had been tested within Qpid's 12 month window. Dependence on any 12 month old lab result is highly likely to lead to new infections, not to prevent them.
I'm sure the prevalence of texting phones is high in gay men, but it is not universal, and any service that requires testing within 12 months is going to face the same issues that testing itself faces. Fear of a positive result will discourage people from signing up. Positive men have no reason to sign up in the first place, no matter how honest they are about disclosure. If the percentage of users remains small, the value of the service is low, even if the test results given were immediate and accurate. Qpid offers zero protection against those who lie about their status, as they simply won't be subscribers, and given the "low penetration" of the service," someone who uses it is going to find a lower percentage of users than "certified negatives." I simply cannot imagine many men saying, "Since you don't have Qpid, I won't go home with a horny man who looks like a Colt Model." Sexual decisions are, for better or worse, almost never that mathematical.
I suppose it's possible it might encourage a few kind of nerdy and paranoid men to be tested, and that's a good thing. The bottom line is that only safer sexual practices, honest discussion, and education can really help.
In short, I think Qpid cannot deliver reliable laboratory information that increases safety, because it depends on old results in a population with lots of recent infections. I do not believe it could ever reach a percentage of users that would allow it to be of use in the first place…
and I hope they have a team of lawyers specialized in HIPAA issues, because they're going to need it.
Monday, July 9, 2012
Home HIV tests
The FDA recently approved a home test kit for HIV that will allow you to buy a test, and get a result within an hour. There is a number to call to get information and counseling, but the result will be right there.
There are, as with anything, plusses and minuses. For people who cannot be seen getting tested, and there are many, this test will be a huge advance. They will be able to get result, and move forward to seek therapy on their own. It is thought that this will be a particular help to communities where "stigma" deters people from testing. If it works out that way, it is estimated that up to 40,000 new HIV infections will be avoided every year.
I have concerns for sexually active gay men. While the test is good, and based on the "orasure" technology that has been used for years, there are a couple of problems. First, these tests only measure antibodies, unlike the latest blood tests, which also measure virus itself. The home test has a three month window period. Tests done in a medical lab using blood have reduced the window to a week or so. In young people hooking up on the net, this is vital.
Secondly, when done at home, this test has a very significant false negative rate. For every 12 truly positive tests, there will be one person who gets a negative result, but who is, in fact, positive. Using this test to screen sex partners for bareback sex could easily allow lots of new infections.
I do not believe this test is ideal for sexually active gay men, and it is a very bad idea to use test results from the home HIV test to make decisions about bareback sex.
Sunday, September 4, 2011
The following is an excerpt of a posting in a forum about HIV issues. The original posting was from a man who was infected in a "monogamous" relationship. The man had been infected by his partner, who was positive, and lied over several years, while they had unprotected sex. Personally, I find that kind of lie morally repulsive, and probably criminal. Many notes echoed the following sentiments:
"YOU chose to have unprotected sex. Regardless of the fact that he was your boyfriend in a 'supposed' monogamous relationship or that he lied, you still chose.
I tell you, everyone needs to take accountability for their own actions. It's not about who lied to you, it's about what you allowed. It's your body. If you don't want HIV or STI's, then don't bareback, regardless of it being a partner monogamously or not. If you're willing to accept the possible risks, then do what you want as long as you don't come crying later.
Yes, to most everyone, it's a criminal thing to keep going around and infecting others, but those people are somewhat just as stupid for 'believing' him in the fact that he says he's negative and having bareback sex due to believing him. I just don't understand why it's ALWAYS the poz guy's fault. EVERYONE takes accountability.
And there's always Karma. You keep doing evil things, something big is gonna back to bite ya. And for the things i've seen, it always has come back 10 fold, so i tend not to worry about those people. I worry more about the people who don't think with their heads appropriately.
I find it really funny in the online world too where people will ask status of someone (after claiming to want bareback sex) and that someone will be honest either saying, yes they are poz or that they are neg from their last test but that's only as good as the last test and they bareback, so truthfully, one could claim they don't know for sure. The other guy will say, "well, i don't want to take the chance if you don't know", yet he'll believe others so easily that say they're neg.
Fools, i say. This is the way it's been and always will be. Some get caught, some don't and we wish they would. In the end, REALLY, we have to take accountability for ourselves.
I refuse to play the blame game. I made my own choices, i knew exactly what the possible outcomes & consequences were."
I tell you, everyone needs to take accountability for their own actions. It's not about who lied to you, it's about what you allowed. It's your body. If you don't want HIV or STI's, then don't bareback, regardless of it being a partner monogamously or not. If you're willing to accept the possible risks, then do what you want as long as you don't come crying later.
Yes, to most everyone, it's a criminal thing to keep going around and infecting others, but those people are somewhat just as stupid for 'believing' him in the fact that he says he's negative and having bareback sex due to believing him. I just don't understand why it's ALWAYS the poz guy's fault. EVERYONE takes accountability.
And there's always Karma. You keep doing evil things, something big is gonna back to bite ya. And for the things i've seen, it always has come back 10 fold, so i tend not to worry about those people. I worry more about the people who don't think with their heads appropriately.
I find it really funny in the online world too where people will ask status of someone (after claiming to want bareback sex) and that someone will be honest either saying, yes they are poz or that they are neg from their last test but that's only as good as the last test and they bareback, so truthfully, one could claim they don't know for sure. The other guy will say, "well, i don't want to take the chance if you don't know", yet he'll believe others so easily that say they're neg.
Fools, i say. This is the way it's been and always will be. Some get caught, some don't and we wish they would. In the end, REALLY, we have to take accountability for ourselves.
I refuse to play the blame game. I made my own choices, i knew exactly what the possible outcomes & consequences were."
Everyone is responsible for their own health, but nobody is absolved of the responsiblity to avoiding another person, even if that person makes a foolish choice.
Tuesday, March 8, 2011
He must be........or he wouldn't do that/be here.
I keep hearing this one: Went to the baths, had unsafe sex. The negative guys think, "damn, he's hot, doesn't look sick, no reason to worry." Poz guys think, "If he were not poz already, he wouldn't be in the baths with his butt in the air and the door wide open.
Ask. Tell.
This quiet misunderstanding is leading to lots of new infections. You can't tell by looking. You can't guess by risk taking or geography.
Wednesday, February 2, 2011
Dealing with it
I found this written on another chat list, and thought it was so good that I asked the writer, Brian, if I migh post it here.
"The "eroticizing" of HIV has become much more pronounced in the last 5-7 years. For some, the premeditated act of potentially giving or receiving the virus heightens sexual pleasure for them. They go around using terms like "breeding" and "seeding", getting guys "pregnant" etc...as if this act links these men in some sort of unbroken bond. A brotherhood of sorts. I don't claim to understand it, but those are the facts.
Another fact, however, is one that footlicker alluded to in his original post: the reality of living with the disease. For these men, the idea of "acquiring" the disease seems to be the focus without any regard for the actual "possession" of it. In other words they seek it out as fantasy but most times are not prepared for the realistic damage it causes to their bodies, psyche, or lives. I hear talk of a sense of "freedom" that these men think the infection will bring them in terms of sexual behavior, but that couldn't be further from the truth.
Here is the truth:
There isn't such thing as freedom in relation to this disease. You are a prisoner to medications. You are a prisoner to public perception to the disease itself. You are a prisoner of doctor visits, potential opportunistic infections, and therapy failure due to resistance issue. We don't even need to talk about the fact that your risk of dying from cancers, heart disease and stroke increases dramatically post infection. Oh, and shortened life span kind of puts a damper on things as well.
Rather than the world opening up for you sexually, be prepared to spend more time in the fantasy of having sex rather than the actual act itself because the overwhelming majority of the world DON'T want the infection you worked so hard to get, and will in most cases avoid that type of contact with you. Just look around this forum. How many men have posted here discussing their struggles regarding relationships, sex partners, difficulty finding love and acceptance, and of course fear of disclosure regarding their status? Now that you so proudly and actively sought out the disease, do you intend to trumpet your success in getting it to everyone you meet? I doubt it.
THAT is the reality of this disease. Not so glamorous after all is it?"
Another fact, however, is one that footlicker alluded to in his original post: the reality of living with the disease. For these men, the idea of "acquiring" the disease seems to be the focus without any regard for the actual "possession" of it. In other words they seek it out as fantasy but most times are not prepared for the realistic damage it causes to their bodies, psyche, or lives. I hear talk of a sense of "freedom" that these men think the infection will bring them in terms of sexual behavior, but that couldn't be further from the truth.
Here is the truth:
There isn't such thing as freedom in relation to this disease. You are a prisoner to medications. You are a prisoner to public perception to the disease itself. You are a prisoner of doctor visits, potential opportunistic infections, and therapy failure due to resistance issue. We don't even need to talk about the fact that your risk of dying from cancers, heart disease and stroke increases dramatically post infection. Oh, and shortened life span kind of puts a damper on things as well.
Rather than the world opening up for you sexually, be prepared to spend more time in the fantasy of having sex rather than the actual act itself because the overwhelming majority of the world DON'T want the infection you worked so hard to get, and will in most cases avoid that type of contact with you. Just look around this forum. How many men have posted here discussing their struggles regarding relationships, sex partners, difficulty finding love and acceptance, and of course fear of disclosure regarding their status? Now that you so proudly and actively sought out the disease, do you intend to trumpet your success in getting it to everyone you meet? I doubt it.
THAT is the reality of this disease. Not so glamorous after all is it?"
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