(RITA!) HIV Treatment Alerts - May 2003
Ben J. Barnett, MD, answers some of the toughest questions from ALERTS! readers yet.

Q: I have tried to get vaccinated for Hepatitis B (HepB) with no success. I went through the series of 3 vaccinations at 2 different times but still show no antibodies to HepB in my blood. Is this common in people with HIV? If I am taking a drug like Epivir or Viread (which can be used to treat Hep B, right?), will that prevent me from getting HepB?

A: About 10% of HIV-negative persons will not have antibodies to HepB after the routine series of 3 vaccinations. About half of those people will go on to have antibodies against HepB after a second series of 3 vaccinations. However, the other half will remain as "non-responders" to the vaccine. In HIV+ persons, the response rate to the vaccine is somewhat lower, and persons with T cell counts less than 200 have a very high rate of vaccine failure. So, if you have had the vaccine series twice and did not respond, no further vaccination is recommended. Instead, you should practice basic prevention measures (such as condom use during sex and using clean needles if you use injection drugs) to avoid transmittable diseases like HepB. Epivir and Viread are drugs that can treat both HIV and HepB, but there is no evidence that taking them will prevent infection with either virus.

Q: I have been on Trizivir (Retrovir, Epivir, and Ziagen) for 2½ years, and my virus is starting to show signs of resistance to the drugs. My last 3 viral loads were 800, 2100, and 7300 at 2 months apart. I am getting a resistance test next week. I have taken no other drugs. If my virus is very resistant to the 3 drugs in Trizivir, what are my options?

A: The drugs that are in Trizivir are all in the same class of medications for HIV, called nucleoside reverse transcriptase inhibitors ("nukes"). If you do indeed have resistance to all 3 nukes, it unfortunately does mean that the virus may be also resistant to other nukes, such as Zerit. However, depending on the results of your resistance tests next week, drugs like Viread or Videx may still be good options. You and your doctor will need to discuss your specific case. The good news is that resistance to Trizivir will not affect the ability of the other kinds of drugs (non-nukes, protease inhibitors, or the recently approved fusion inhibitor) to keep HIV under control.

Q: Five months ago I started meds and am taking Sustiva and Combivir (Retrovir + Epivir). So far, I have been doing OK (my viral load went from 70,000 to undetectable), but I am getting dizzy spells and fainting, and my doctor thinks it's the Sustiva. Should I change meds? To what?

A: Sustiva certainly can cause all sorts of nervous system side effects like nightmares, dizziness, and depression. Usually, these symptoms go away after a few weeks, but they can last longer. If your doctor thinks your symptoms might be related to Sustiva, and because you are doing so well with an undetectable viral load, I think it is safe for you to substitute another drug for Sustiva and see if your symptoms go away. Options for you to discuss with your doctor would be Viramune, which is in the same family of medicine as Sustiva, or perhaps a protease inhibitor. It is very important to remember that you should not just stop the Sustiva and see if your symptoms go away, because then you would only be taking 2 drugs for HIV (Retrovir and Epivir) and that is not an adequate treatment regimen by itself.

Q: I have been on meds (Kaletra, Viread, and Epivir) for a year now, with a viral load between 100 and 400 (it varies), but my T cells have not gone up from 230. Shouldn't they go up? Is there anything I can do to raise my T cells?

A: Generally, T cells will go up after successful treatment of HIV, but the response is not the same in all patients. Sometimes, the T cell count will rise very quickly, and sometimes it takes several years, if it goes up at all. It is not clear why this difference exists. One factor is that older patients tend to have a smaller and slower rise in T cells, but unfortunately none of us can get any younger! Another factor is co-infection with hepatitis C (HepC), so if you have HepC infection, perhaps getting treated for that will help your T cells go up. Also, using drugs like cocaine can make T cells go down, so if you use cocaine, a drug treatment program may help. Your viral load is undetectable by the standard test (less than 400) but not by the "ultra-sensitive" test (less than 50). Perhaps adding a fourth drug to your regimen might drive your viral load down to less than 50, and this might help with your T cell count. Finally, there is a drug being studied called interleukin-2, which you could talk to your doctor about, that might increase your T cell count. I'd encourage you to remain patient because I've seen people have almost no rise in T cells at 1 year, but then have a large increase in their T cells later.

Ben J. Barnett, MD, is an assistant professor of medicine at The University of Texas Houston Medical School, and a staff physician at Houston's Thomas Street Clinic.

Send your questions for physicians to rita@centerforaids.org or by mail: Questions, P.O. Box 66306, Houston TX 77266-6306.

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Copyright © 2003 - Research Initiative Treatment Action (RITA!). Reproduced with permission. RITA! is published by The Center for AIDS. Contact Thomas Gegeny, MS, ELS, Editor, RITA! for permission to reproduce RITA!. tom@centerforaids.org. http://www.centerforaids.org

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