Few issues in HIV are more controversial than HIV-infected individuals having children. Even when adopting a child, people with HIV may be criticized because their disease may cause illness that could interfere with parental responsibilities. Obviously, the possibility of the child becoming an orphan is also an issue. However, people with HIV who are taking anti-HIV medications (when needed) are living longer, healthier lives.
Advances in anti-HIV therapy and improved treatment of opportunistic infections have produced a significant increase in the life expectancy and quality of life of HIV-infected adults. Since the majority of HIV-infected men and women are of reproductive age, many are likely to consider becoming parents. To date, most of the attention in reproductive HIV medicine has focused on preventing mother-to-child (vertical) transmission of HIV.
In 1987, while practicing in a walk-in pediatric clinic, I encountered an infant who was born to a newly diagnosed HIV-infected mother. At that time medical understanding of HIV infection was rudimentary at best, and our knowledge of pediatric HIV was even more primitive.
People with HIV face a number of medical, social, legal, and emotional issues associated with their diagnosis. Twenty years ago, in the beginning of the epidemic, HIV/AIDS was considered a fatal diagnosis, and the emotional issues were often those of loss: of health, of body image, of income, of family and friends, and of time. Entire social service agencies were established for gay men with HIV/AIDS to address many of these issues. Support groups and networks flourished to meet those social and emotional needs. But the so-called face of HIV/AIDS has changed and now increasingly reflects a female face, frequently poor and often a woman of color.
Ingrown toenails still a possible side effect. A case series report published in The Annals of Pharmacotherapy (35, p. 881, 2001) has confirmed the well-established link between the protease inhibitor indinavir (Crixivan) and complications like ingrown toenails.
Research continues to point to the benefits of improved diet, stress reduction, and exercise in HIV-infected people. One recent study, published in Clinical Infectious Diseases (33, p. 710, 2001), looked at the dietary habits of 85 HIV-infected men and women with symptoms of lipodystrophy. Each person was evaluated for dietary intake of alcohol, fiber, and fats; waist-to-hip ratio; body mass index; pattern of body fat changes; use of protease inhibitors (and for how long); and basic characteristics like age and sex.
Highly active antiretroviral therapy (HAART) has revolutionized the treatment of HIV infection and offers many patients real hope of long-term survival without the acute complications of AIDS. However, a syndrome of body shape changes (commonly called lipodystrophy) has recently emerged that includes visceral (gut) fat accumulation, peripheral (arms and legs) loss of fat, high levels of fat in the blood, and even diabetes. These changes closely resemble a number of inherited non-HIV-related forms of lipodystrophy syndromes. Researchers are still not sure how much of this syndrome may be caused by anti-HIV drugs or by the virus itself.
In my first few months as director of education and outreach here at The Center for AIDS (CFA), the world has turned topsy-turvy. The events of mid-September have affected us all. Upon receiving a recent phone call from a frantic person whose viral load had "spiked" from undetectable to 200, and several others like it, I pondered why this infinitesimal rise in HIV would cause someone such concern. The answer is simple and profound: uncertainty about life after September 11 has created increased anxiety about life in general, and to some degree, living with HIV.
The Montrose Counseling Center is a nonprofit, community-based organization providing culturally affirming, quality, and affordable outpatient mental health, substance abuse treatment, and case management services, as well as education and research in Metropolitan Houston and surrounding areas. Services are provided primarily for and about gay, lesbian, bisexual, and transgender individuals and their significant others.
As if the stigma of infection wasn't bad enough, people with HIV/AIDS have to worry about complications caused by the virus, opportunistic infections, or even the medications used for treating HIV. This issue of HIV Treatment ALERTS! includes a review of medical emergencies for the HIV-infected person. These are situations where that person's life might be in danger, and an emergency room visit might be necessary. It is not only important for the emergency room doctor to be aware of these issues, but also the patient. In addition, there is an article on strategies for regaining control of cholesterol and triglyceride levels. High blood fat levels are a problem for people with HIV/AIDS, especially those on certain medications like protease inhibitors.
Edgardo Li-Espino, MD, Hilda Cuervo, & Roberto C. Arduino, MD
The University of Texas–Houston Medical School
Human immunodeficiency virus (HIV) is associated with several diseases that may be life threatening and need quick intervention by health care workers. These emergencies could be related to complications from the use of anti-HIV medication or to opportunistic infections that occur as the immune system gets weaker. This article summarizes some conditions that can be considered medical emergencies in HIV-infected individuals.
Ben J. Barnett, MD, The University of Texas–Houston Medical
School, & Mario Maldonado, MD, Baylor College of Medicine
In the 20 years since AIDS was first described, there have been many advances and disappointments. One of the greatest advancements has been the discovery and use of highly active antiretroviral therapy (HAART). Unfortunately, we are now learning of the many possible types of metabolic side effects that come with these treatments, including body fat changes (lipodystrophy), insulin resistance, and diabetes, among others. We are also seeing increases, sometimes to extreme levels, in the amounts of cholesterol and triglycerides (types of fat) in the blood, a syndrome called dyslipidemia. It is possible that these metabolic complications will increase the chances of a heart attack or stroke. This article summarizes what you need to know as a patient about your levels of blood cholesterol and triglycerides.
Benefits of drug-resistant HIV? For HIV-infected individuals with drug-resistant virus, piecing together a drug regimen that can suppress the virus is a major challenge. When HIV is drug-resistant, it carries changes that allow it to reproduce in the presence of drug. However, there may be some hope for heavily treated individuals with drug-resistant virus. Research suggests that drug-resistant HIV may not always reproduce or attack T cells as well as natural or "wild-type" HIV.
Bottom line: don't panic if your viral load becomes detectable at a low level once in a while. Your health care provider can monitor your viral load more frequently and recommend therapy changes only if it becomes necessary.
They call it SMART and it launches on Monday, October 15, 2001. SMART stands for Strategies for the Management of Anti-Retroviral Therapy, and it will be the largest, most ambitious clinical trial in the history of the HIV/AIDS epidemic. The study will involve 6000 patients and last for as long as 8 years.
Edwin Cordray, DDS, answers some important questions about HIV and the mouth
Q: I occasionally get sores in my mouth and have a gel my dentist gave me that helps them heal faster. Lately, I have been getting sores on my tongue that turn white and seem to spread, with dead skin that I can scrape away. The gel helps, but should I be worried about this?
Some of the nation's most prominent HIV treatment activists will gather in mid-August under the Texas sun. Meeting in Houston, the activists will attempt a historic first: organizing a nationwide community advisory board (CAB) for advocates in HIV basic science and drug development.
The PWA Coalition (established in 1986) is an organization of, by, and for people with HIV/AIDS (PWAs) that promotes independence and self-reliance so that PWAs may live with dignity, self-esteem, and acceptance. The coalition provides short-term crisis intervention and long-term referrals and works to create opportunities for participation in the PWA community, including public advocacy to address the needs of PWAs.
June 2001 marks the 20th anniversary of AIDS in the United States. Although HIV apparently has had a long evolutionary journey, mainly through other primates, it now has the distinction of being a leading cause of human death worldwide. Almost half a million Americans have died of AIDS complications, while between 700,000 and 900,000 are believed to be HIV-infected. The number of deaths and infections worldwide are many millions more. The question now, as always, is When will we find a cure or a vaccine?
Emily Bass, Senior Correspondent American Foundation for AIDS Research
A small group of community advocates, a divided research community, huge sums of money, and urgent questions that threaten to break the mold of conventional trial designs—all of these elements are at play in what may be one of the least publicized and most critical fields in HIV research today: long-term trial design. The National Institute of Allergy and Infectious Diseases (NIAID) has earmarked approximately $80 million for studies to answer such crucial questions as when to start and when to change HIV therapy. Some trials, particularly large, international collaborations, could cost even more.
Meeting in San Francisco on January 29, 2000, activists from across the nation undertook a day-long discussion of the need for research into the long-term effectiveness of antiretroviral therapies. This meeting followed a National Institute of Allergy and Infectious Diseases (NIAID) workshop in Bethesda entitled Long-term clinical studies in HIV infection.
Now that the federal government has given it final approval, SMART will be the largest, most ambitious clinical trial in the history of the HIV epidemic. In fact, it will be one of the largest trials in the history of any infectious disease.
In addition to the primary study question, SMART will generate data for subset analyses on quality of life, cost effectiveness, HIV transmission risk behavior, and probably metabolic complications. Data for a given subset analysis will be gathered only from those sites preselected for the particular question.
This is an incomplete draft provided as a preliminary schema of the study schedule. Please refer to the final CPCRA-approved protocol for the official schedule of events.
In early November 2000, a group of about 20 HIV treatment activists sent a letter to Anthony S. Fauci, MD, Director of the National Institute of Allergy and Infectious Disease (NIAID), expressing serious reservations about a possible federally-funded when-to-start trial (WTST) for antiretroviral therapy.
We at The Center for AIDS acknowledge ourselves to be supporters of the Community Programs for Clinical Research on AIDS (CPCRA) and its SMART study. However, the running of such a study poses formidable challenges to the CPCRA; the study design itself, while intelligent, is not without limitations.
David Barr, Immediate Past Executive Director of the Forum for Collaborative HIV Research
Where is the outcry from AIDS advocates following the recent change in the US government's adult HIV treatment guidelines? The guidelines panel sponsored by the National Institutes of Health (NIH) changed its recommendation from starting highly active antiretroviral therapy (HAART) at 500 CD4 T cells/mm3 to 350 CD4 T cells/mm3. New British guidelines have gone even further, recommending treatment not start until 200 CD4 T cells/mm3. These changes are based on 2 central premises: 1) the development of drug resistance and side effects that are leaving patients with fewer treatment options over time, and 2) data from multiple (mostly European) cohort studies that indicate no significant difference in response to treatment in people starting at 500, 350, or 200 T CD4 cells/mm3.
Welcome to the first issue of HIV Treatment ALERTS! This newsletter is for persons affected by HIV and their caregivers. Inside each issue, you will find the latest HIV/AIDS treatment information on drug interactions, side effects, new therapies, and much more.
The Annual Retrovirus Conference is the major HIV scientific meeting in the United States. Each year, 3500 healthcare providers, researchers, and community activists meet for 5 days to review the latest developments in the field of HIV. You can learn more about the conference, and even hear some of the science lectures, by visiting the conference website: www.retroconference.org. The following are some reports from this year's 8th Retrovirus Conference.
At the recent Retrovirus Conference in Chicago, the pendulum continued to swing again regarding a standard way to treat HIV. In the mid 1990s, highly active antiretroviral therapy (HAART) was introduced with much excitement. HAART is commonly called "combination" or "cocktail" therapy. The regular use of HAART regimens led to improvement in the health of HIV-infected patients, but its widespread use also created challenges and dilemmas for clinicians. In 1996, the assumption was that if therapy could completely suppress virus, it could prevent destruction of the immune system, prevent drug resistance, and lead to a possible cure. This strategy resulted in the concept of "hit hard, hit early." Unfortunately, many of the assumptions about this strategy have proven to be incorrect.
Fehmida Visnegarwala, MD - Baylor College of Medicine
There is growing emphasis on long-term toxicities with the use of highly active antiretroviral therapy (HAART). A total of 8 conference sessions were devoted to these issues. The following metabolic complications are now associated with the use of HAART: dyslipidemia (abnormal blood levels of fats like cholesterol and triglycerides), lipodystrophy (fat wasting and accumulation in different parts of the body), insulin resistance, new-onset diabetes, retinoid (vitamin A) changes, lactic acidosis, and sexual dysfunction.
Liver failure is on the rise. A study reported in the journal Clinical Infectious Diseases (32, p. 492, 2001) indicates that more and more HIV infected patients are dying from liver disease. The increase in death from this cause may be explained by the fact that liver disease may be accelerated in patients with both hepatitis C and HIV. In the study, the researchers looked at the causes of death for patients at the Lemuel Shattuck Hospital in Massachusetts during 3 time periods.
Interleukin-2 (IL-2), also known as T cell growth factor, is being studied as an immune-boosting therapy for people with HIV. There's no question that IL-2 raises T cell counts; the only question is whether those increases translate into what physicians call a clinical benefit. In other words, do people with IL-2-induced increases in their T cell count live any longer or have fewer illnesses than people without the increases? That's important to find out, especially since IL-2 is expensive and its side effects are harsh.
AVES works to empower communities by respecting differences in language, culture, and sexual identity. The organization is committed to stopping the spread of HIV and serving as a bridge to close gaps that impede access to care. The mission of AVES is to promote a healthy community through education, disease prevention, advocacy, and direct care to Latinos and other historically underserved populations.
This information is designed to support, not replace, the relationship that exists between you and your doctor.