Patrick McNamara, M.D., answers questions about starting meds, controlling diarrhea and a new approach to treating facial wasting.
Q: I am a 27-year-old male who just tested HIV positive last March. My T cells are 345 now (down from 372 in March) and my viral load is 23,000. I am not on meds. Some friends tell me to wait a bit longer, and others say to start right away. I am scared that each day I wait injures my immune system more. When should I start taking treatment and with what meds?
A: You need to have a consultation with your physician to thoroughly discuss the potential benefits and risks of early versus delayed therapy. Individuals who develop symptoms from their HIV infection or have fewer than 200 T cells clearly benefit from immediate treatment. The risk of developing a life-threatening illness is increased in HIV-positive people who are not taking HIV medications or appropriate antibiotics to prevent a serious opportunistic infection. Fortunately, this is not the situation that you currently face. My advice is that you monitor your counts closely; get proper rest, exercise and nutrition; and use this time to educate yourself about HIV infection and its treatment. Your T-cell count and viral load may go up, down, or stay the same. For now, you are not putting yourself at risk by waiting and you will develop a better feel for the course or progression of your particular infection. When you are educated about your HIV and committed to following through with treatment, then that is the time to start treatment. Specific treatment options can be discussed at that time.
Q: I have constant diarrhea. I am taking loperamide (Imodium), but it doesn't seem to help. I have only 40 T cells, but the meds I started 6 months ago are keeping my virus undetectable, so I am hoping the T cells will bounce back with time. I am taking Viread, Emtriva and Sustiva, plus some other meds to prevent opportunistic infections. Can you suggest something to control my diarrhea better?
A: This is a very common problem among patients with HIV infection. Medications frequently can cause or worsen diarrhea. However, the meds you are taking are not usually associated with this problem. Other infections such as Shigella or Giardia are common and easily treated sources of diarrhea. With a T-cell count under 100, infections such as Cryptosporidium, Microsporidium and cytomegalovirus (CMV) become more prevalent. Although examination of the stool may reveal these infectious organisms, a colonoscopy is frequently required to make the diagnosis. In the meantime, diarrhea may be improved through the use of diphenoxylate, calcium supplements or cholestyramine resin.
Q: I have had HIV for almost 10 years. I have been on several combinations of meds but am stable now on Viramune, Ziagen and Epivir. My T cells are 380 and my viral load is less than 400. My problem is with fat wasting in my face. My cheeks are sunken in and I am very self-conscious about this. I heard that a treatment called "Sculptra" is available. What is it, will insurance pay for it and how well does it work?
A: On August 3, 2004, the FDA approved Poly-L-lactic acid (Sculptra) for the treatment of HIV-associated facial wasting. Poly-L-lactic acid is a sugar polymer that stimulates the body to produce collagen (a natural skin protein) and therefore replace the tissue that has been lost because of fat wasting. Sculptra has been available in Europe as "New-Fill" for decades and has been demonstrated to be safe and effective. I was fortunate enough to receive training by researchers in London 3 years ago. Since that time, I have treated many patients with facial wasting. The satisfaction with this procedure has been uniformly positive. Treatment with Poly-L-lactic acid is performed by laying down a thin layer of the polymer, usually once a month, until the desired effect is achieved. Depending upon the degree of facial wasting, patients may require 3 to 6 treatments. It definitely works. The challenge now is to convince insurance companies that this is not a cosmetic procedure, but a restorative one. I have encouraged patients to submit claims to their insurance companies and have been assisting them in their efforts to be reimbursed. A patient-assistance program is being developed by the manufacturer, Aventis/Dermik, and will likely be administered through physicians who are currently authorized to treat patients with Sculptra. Please investigate this option. There is no need to feel self-conscious about your appearance.
Patrick McNamara, M.D., is an HIV specialist in private practice in Houston, Texas. He is also the medical director of The Skin Renewal Center, which specializes in the treatment of HIV-associated facial wasting.
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This article was provided by The Center for AIDS. It is a part of the publication HIV Treatment ALERTS!. Visit CFA's website to find out more about their activities and publications.