HIV Treatment Alerts - June 2004

Wayne Bockmon, MD, fields questions on a variety of HIV-related topics.

Q: I am female, 44 years old, and have had HIV for 8 years (taking HIV medications all that time). My T cells have ranged from 320 to 550 (where they are now) and my viral load is less than 50. Are there any vitamins, supplements, or medications I can take to help keep me healthy? One friend mentioned that I should take fish oil, baby aspirin, vitamin B, and a multivitamin. Do you agree? Is there anything else?

A: I think your friend's advice is sound. The issue of what vitamins and supplements are advisable for anyone living with HIV is a topic about which even experts disagree. We know that people with HIV have a higher daily requirement of nutrients, including vitamins and essential minerals. We also know from some clinical trial data that people with HIV who do take vitamins and other supplements seem to maintain a healthier immune response. The question becomes how much of what. For a person like you, I think a really good multivitamin including B complex, antioxidants, and trace minerals like zinc and selenium makes sense. The fish oil supplement is a good idea in HIV, especially if you are on medications, because of the beneficial effects on lipids (fats in the blood). People with HIV often have excessive coagulation or blood clotting that can lead to heart and other circulatory problems. The baby aspirin can thin the blood just enough to prevent that. Other nutrients may be recommended depending on your specific needs. A good nutritionist could help you decide if any of the many other supplements would be right for you.

Q: I am a 34-year-old male and have had HIV for 6 years. I have been on and off medications (stopped for 2 years with my doctor's supervision), but was always undetectable while taking them. I get a pain that comes and goes on the right side of my hip. It's particularly uncomfortable when I am sitting on the floor or if I have been standing a lot. An X-ray last year showed no problems, but should I be worried about HIV-related bone problems? Should I get an MRI?

A: Many things can produce joint pain. Osteoarthritis, a condition of aging that we all experience to some degree, could cause your symptoms even at age 34. A physical activity or sport that strains the joint could cause the recurring pain. In people with HIV, however, we sometimes see a serious condition that presents as hip pain and goes by the name of avascular necrosis (AVN). This condition is a loss of adequate blood flow to the bone resulting in actual death of part of the bone. AVN generally will not be picked up on a routine x-ray. An MRI will detect AVN and should be done if it strongly suspected. Factors associated with AVN are steroid use (including megace), smoking, heavy consumption of alcohol, and elevated lipids. If your symptoms are persistent, unrelieved by over-the-counter pain medicines, and if other causes have been ruled out, then an MRI is probably a good idea. AVN is serious and best managed if caught early.

Q: After surviving with AIDS for more than 15 years, I really feel like I am running out of options. The only drug I have not taken yet is the injectable Fuzeon, but my doctor wants to wait for a new drug to come along because I have virus that is resistant to everything currently available. My T cells are 95 and my viral load is 44,000. I am taking Combivir and Viracept just to slow down my AIDS progression if possible. Any suggestions?

A: Good question. I've had many debates with HIV experts about this one and I can tell you that there is no consensus of opinion. Fuzeon is a potent drug, but will only work in the long term if combined with other drugs to which your virus is sensitive. If used as the only effective antiviral, it is doomed to eventual failure. I would start with a genotype test and phenotypetest to see if any of the currently available drugs might be used in some kind of combination strategy with Fuzeon. If not, your next best bet is to locate a clinical trial of a new agent with a unique drug resistanceprofile to pair with the Fuzeon.

Q: Is cryptosporidium still a problem? If so, how do I protect myself from it? I have 380 T cells and a viral load of 12,000 on a combination of Viread, Emtriva, and Sustiva.

A: Cryptosporidium still exists, but fortunately today we seldom see the horror stories of the past when people had no effective treatment for HIV and could not rid themselves of this infection. Cryptosporidiosis in immune-healthy people is a gastrointestinal disease with a predictable course and is characterized by lots of diarrhea. In HIV, especially in those with T cell counts below 200, the infection may not clear and can become chronic and debilitating. With your numbers, you are not at much risk. It's hard to "protect" oneself from exposure to cryptosporidium because it is found in soil and water, including tap water. Some water filtration systems can filter out cryptosporidium. Keeping your T cell count up is the best option. By the way, I notice that your viral load is quite high (12,000) on treatment. This tells me that either you are not taking enough of your drugs to control your virus or that resistance has developed. Two of your drugs can fail with a single mutationin your virus. You need to discuss this with your doctor immediately. Continuing a failing regimen is a formula for disaster, especially when you may still have other options to suppress HIV and keep viral load undetectable.

Wayne Bockmon, MD, is an HIV-treating physician at the Montrose Clinic in Houston.

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 © 2004 - 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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