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Living With HIV -- and Everything Else

Fall 2011

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Living With HIV -- and Everything Else!

Recently, a 55-year-old gay man announced to his dinner companions, "Well, I hear that having HIV is now just about taking one pill a day. I can do that, so I'm going to stop using condoms."

As anyone living with HIV knows, managing this disease is about far more than taking a pill. First, the once-daily pills will only work if you are infected with a strain of HIV that's not resistant to any of the medications in the pill (it's estimated that up to 27% of new infections contain drug-resistant virus). But even if the virus is easily controlled, new research shows that HIV can cause damage even at higher CD4 counts, due to the inflammation caused by HIV's constant activation of the immune system. That's one of the reasons the recommendation to start HIV treatment has been bumped up to include anyone with a CD4 count below 500. Some experts and public health authorities (such as the New York City and San Francisco Departments of Health) are recommending that treatment be offered to anyone with HIV, regardless of CD4 count (although preventing new infections is also a factor in this approach).

And living with HIV often means living with other chronic conditions known as comorbidities. Whether these are caused by another virus (such as hepatitis C) or are one of the illnesses so often seen in older adults with HIV (such as osteoporosis), these conditions complicate the care of people with HIV and make their lives anything but simple. This is not to say that life with HIV is miserable, just that it takes a lot of health management and remains something to be avoided -- especially if the choice is between using condoms or living with a lifelong infection.

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The good news is that people with HIV may live as long as someone who is HIV-negative if treatment is started early enough. But while advances in HIV treatment have saved many lives, the medications used can have side effects that affect different people in different ways. This article will look at some conditions that people with HIV should be aware of, whether they have been on meds for years or are new to them. We'll also examine how people can improve their quality of life without taking more meds.


Lipodystrophy

This condition is defined as the abnormal loss of fat from one area of the body -- usually the face, arms, and legs -- and an increase of fat in the stomach or at the back of the neck ("buffalo hump"). In women, breast size may increase due to fat buildup. Lipodystrophy became well known in people with HIV in the mid- 1990s when combination HIV treatment was first used. Over the years, it has decreased, since the newer meds are less toxic. With the earlier onset of aging associated with HIV and one's own genetics, however, there is still a risk for lipodystrophy later in life. While there are meds that can be used to treat lipodystrophy, they are often very expensive and may not be covered by insurance.

Managing lipodystrophy can be approached in different ways. First, if one is taking meds that have been shown to cause fat loss, switching may help restore some fat or stop further loss. A few studies have already shown this approach to be effective. If one is not able to switch because of drug resistance or other reasons, non-medicine treatment options include weight-bearing exercise and nutritional supplements. Weightbearing exercises include things like bench presses, squats, lat pull-downs, etc., and has been shown to increase lean body mass. Aerobic exercises like running and cycling are not helpful in building lean body mass because they break down muscle even further. If total body weight and lean body mass are stable, however, people can alternate aerobic with weight-bearing exercise. People should talk to their health care provider and an educated trainer before starting any exercise program.

Research also shows a relationship between the fat buildup in the stomach and insulin resistance. This is a condition in which the body's natural insulin becomes less able to lower blood sugars. Fat and muscle cells need insulin to absorb sugar. When these cells don't work properly, blood sugar levels rise beyond the normal range and cause negative health effects like high cholesterol. Supplements such as milk thistle, N-Acetyl Cysteine (NAC), and Alpha Lipoic Acid have all been shown to help the body absorb sugar. Omega-3 fatty acids and carnitine can help lower high cholesterol caused by lipodystrophy. These supplements may also have other benefits, such as reducing fatigue, muscle weakness, and neuropathy (pain from nerve damage).


Wasting

Wasting can also occur in people on HIV meds. Wasting is generally defined as an involuntary loss of 10% or more of total body weight. Changes in metabolism, lack of appetite, low testosterone, gastrointestinal disorders, and changes in the immune system can all cause wasting. It can be due to any one of these conditions or a combination of them. When the body is under attack from infection, lean body mass and muscle are usually the sources of energy the body uses to fight back, which can result in wasting. When meds are able to control HIV, the weight does return, but usually in the form of fat and water weight. This means that lean body mass and muscle are lost and treatment to address this may be needed.

Treatments for wasting vary. They may include nutritional supplements like L-glutamine, protein supplements, testosterone replacement, or treating an infection that is causing diarrhea. Weight-bearing exercise and proper nutrition can also help ward off wasting. Providers may differ in their approaches to diagnosing and treating wasting, so it's best to ask questions to understand the causes of wasting and what can be done to combat it better.


Testosterone

HIV disease can also lower testosterone, needed to build bone and muscle mass. Testosterone also increases muscle strength, increases bone density and strength, and is useful in preventing osteoporosis. Women produce testosterone, but to a much lesser degree than men. Testosterone levels gradually decline with age, usually starting in the late 20s in men.

There is disagreement about if or when to use testosterone replacement or anabolic steroids in older men. There is not even agreement on the level of testosterone below which a man would be considered for treatment. And there are no standards for when to treat women. Identifying severe loss of testosterone in an older man by symptoms alone can be difficult because testosterone levels change based on the time of day and the type of test.

Replacement therapy can be taken by injections, gels applied to the skin, pills, and patches. Negative effects of synthetic testosterone range from minor problems like pimples, oily skin, and hair loss to serious complications like increased red blood cells, which may require removing blood. These side effects are more commonly seen in people who overuse testosterone or steroids.

While there is no proof that testosterone replacement causes prostate cancer, it is recommended that physicians screen for prostate cancer with a digital rectal exam and PSA (prostate specific antigen) test before starting therapy. And if therapy is started, red blood cells and PSA levels should be monitored closely. People using steroids must have regular liver function tests and providers may recommend supplements to boost liver health.

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This article was provided by ACRIA and GMHC. It is a part of the publication Achieve. Visit ACRIA's website and GMHC's website to find out more about their activities, publications and services.
 
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