My friend's first antiretroviral regimen started in November 1996: Viracept, lamivudine (3TC) and Zerit (D4T). 6 years later in 2002 his infection became resistant to those meds, so he switched to his current regimen (Sustiva, Videx, Viread), which has carried him through these past 7 years.

His CD4 is 1100 at 39%, Viral Load <48 (undetectable). His last glucose reading is 7%, triglycerides are 400. He recently restarted treatment with fish oil pills, which seemed to help control the triglyceride problem when he had this problem before. All his other numbers look normal.

My friend has a family history of diabetes. His dad died of it and he lost his brother this summer as well... in his brothers case diabetes was a complicating factor towards saving him. My friend was therefore pre-diabetic at the start of his own antiretroviral treatment in 1996 and over the course of the years and concurrent with his HIV treatment has become diabetic himself.

The frustrating part is that my friend is most disciplined in his efforts to prevent a demise similar to his dad's... he works out at the gym, trains with weights and does his cardio and is pretty strict with his diet as recommended by his doctor and his nutritionist, rarely straying from their instructions and then only with a healthy dose of conscious moderation.

Some years ago he had to start medication to control his sugar and seemed successful at it in concerted application of diet, exercise, monitoring and medication. More recently however, hes become increasingly unable to control his diabetes despite continued discipline and so within the last month was put on insulin and since then dropped 14 pounds. Increasingly, he complains of feeling numbness in his arm and of dizzy spells. His Primary Care Physician currently has him wearing electrodes to monitor his heart for 28 days due to a newly-developed irregular heartbeat.

Over the years Ive also noticed him complaining with increased frequency of streaks of depression, which he and his doctor attribute to his meds and for which he to-date has declined anti-depressive medication in order to limit ingested chemicals and because his depressive streaks typically last no more than a couple or few days at a time. His doctors are all aware of these symptoms and are his partners in formulating these choices.

My friend is leery of changing his regimen for fear of eliminating treatment options down the road and especially given what he perceives to possibly be a futile effort anyway, since he says any change would call for a protease inhibitor that would likely only exacerbate the problem. Are his assertions correct and does this mean that he's condemned to living with worsening diabetes despite his most disciplined efforts? Is there anything else he might try?

This is his current list of medicines:

ANTIRETROVIRALS

~ Sustiva 600 mg ~ Viread 300 mg ~ Videx 400 mg

DIABETES CONTROL

~ Glucaphage (Metformin) 1000 mg BID ~ Byetta Insulin 10 mg BID

CHOLESTEROL MANAGEMENT

~ Antara 130 mg ~ Simvastatin 40 mg

OTHER

~ Acyclovir 400 mg BID ~ Fluocinolone cream 120 mg ~ Proctozone cream 20 mg ~ Omega Brand Fish Oil Pills

Depending on your friend's full HIV treatment history and resistance status, he may benefit from switching off the Videx and Zerit to alternative NRTIs such as a tenofovir or abacavir based regimen. Raltegravir appears to have little effect on metabolic parameters so that could be an option to consider as well. In some cases diabetes presents major challenges for control independent of an HIV or HIV drug treatment specific effect. KH