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Patient/Doctor Q&A

Gary Brewton, M.D., Tackles Some Tough Patient Questions

November 2001

Q: I began taking d4T and 3TC in 1996 with a viral load of almost 30,000 and a T-cell count of about 380. The drugs kept my viral load undetectable and my T-cell count as high as 950. However, I got off drugs one year ago when signs of peripheral neuropathy (pain and loss of sensation in my feet) and lipodystrophy (veins popping out all over my arms and legs and a fat pad on the back of my neck) started to really affect me. I now have a viral load of 11,000 and a T-cell count of 700. When should I restart therapy, and if I do, can I still try a 2-drug regimen in order to save my options for the future?

A: Most physicians would not recommend resuming treatment at present with the test results you describe, unless there was some other indication for treatment such as unexplained fever, weight loss, thrush, or HIV encephalopathy (brain disease). Whether you will be able to remain off treatment indefinitely is uncertain, so for my patients in a similar situation, I recommend re-evaluation every 3 months with blood tests and a visit to the doctor. If the viral load goes above 50,000, if the T-cell count goes below 500, or if symptoms of HIV disease emerge, I'd repeat the tests sooner, say after one additional month. If these results remain unfavorable, I'd consider restarting treatment. If your virus escapes from control by your own immune system, the T-cell count can drop abruptly, so it is important to closely monitor you while not on treatment. For an excellent discussion of the subject of immune control of the virus, see the chapter by Bruce D. Walker, M.D., in the HIV/AIDS Annual Update at the Medscape Web site. (Medscape requires a free, first-time only registration.)

What treatment to use in that case depends on several factors: 1) the likelihood that the virus would be sensitive to the d4T (Zerit) and 3TC (Epivir) you previously took, which I would estimate to be good since your viral load was undetectable when you stopped treatment; 2) the likelihood that if you took these 2 drugs again you would experience the same symptoms that caused you to stop the treatment one year ago, which (at least in the case of neuropathy) I would judge to be high; and (3) the feasibility of constructing an alternate combination of 2 or perhaps 3 drugs that would likely have durable and potent benefits. Considering all these factors, if you were willing, I might suggest a 3-drug, nucleoside-based regimen such as AZT (Retrovir), 3TC, and abacavir (Ziagen) combined in 1 pill taken twice a day (Trizivir). I would not introduce drugs you have never taken before, except as part of a 3-drug regimen. If you preferred a 2-drug regimen, you could give d4T and 3TC another try, but the risk of recurrent symptoms might make this less appealing to you.

You did not mention whether your symptoms got better being off treatment the last year. I'd expect the neuropathy did improve, but the lipodystrophy did not.

Q: The drugs I am taking for my HIV give me diarrhea. Are there any ways to minimize this side effect? I have tried products like Imodium, but with very limited success. What would you suggest?

A: First, I'd test to make sure that there is no treatable cause of diarrhea such as infection with Clostridium difficile, Giardia lamblia, Entamoeba histolytica, or other intestinal pathogens. Three separate stool samples are required to be certain there are no parasites, since even the best laboratories can only screen with about 70% accuracy. Each sample for ova and parasite examination ("O&P") must be placed into appropriate transport media containing preservatives within 30 minutes after the stool is passed. You might also want to try eliminating lactose (all dairy products) from your diet to see if this helps, since lactose intolerance is common -- especially in non-Caucasians.

Assuming no other cause of diarrhea is identified, a number of adjunct therapies make a major difference in the control of diarrhea due to HIV medications. First, using a regular daily dose of loperamide (Imodium), perhaps as little as one pill every day, seems to help people better than using loperamide on an "as needed" basis. Second, fiber supplements such as psyllium (Metamucil) and methylcellulose (Citrucel) are useful to absorb the excess water content of the stool, making the bowel movement firmer. Fiber may also reduce elevated cholesterol levels, which are another complication of HIV therapy. Third, calcium supplements help reduce diarrhea and may reduce the risk of osteoporosis (bone loss) and avascular necrosis of the femoral head (hip degeneration), also seen in people with HIV. Finally, the amino acid glutamine may also be helpful.

Q: I am reasonably healthy (T-cell count is 450, viral load is 600) and have not experienced any symptoms of AIDS in the 7 years I have been HIV positive. I heard that getting tuberculosis can make my HIV disease worse. What should I do to protect myself from getting TB? Are there other things that I should worry about?

A: Pulmonary tuberculosis (TB) is a concern for people with HIV infection. The primary way to avoid getting TB is to avoid contact with individuals who have it and are contagious. Prolonged contact is frequently required to transmit TB. Settings such as prisons, hospital wards, group residences, and homeless shelters contribute to outbreaks of TB. Transmission can occur by travel to countries where TB is endemic. Earlier this year there was a report of a cluster of 18 TB cases in Kansas that occurred from 1994 to 2000 among women with a history of working as dancers in adult entertainment clubs (exotic dancers) and persons who were close contacts of exotic dancers (Morbidity and Mortality Weekly Report 50:15, p. 291, 2001).

After first getting infected with the TB germ, most people develop a latent infection as the body's immune system, at least temporarily, controls the TB infection. In this latent stage the TB is not transmitted to other people. As time goes on, the latent infection can become active, and then it can be spread to other people by droplets containing the TB germs that are produced when the person with active TB coughs, talks, laughs, or sneezes. In someone with HIV, the risk of developing active TB disease is 10% to 15% per year, much higher than for someone without HIV. Treatment for latent TB (to prevent development of active TB disease) is given if a person has a positive skin test and has not previously received TB treatment or if the person has close contact with a patient with active tuberculosis. It is very important for individuals to complete the prescribed course of treatment, which can last up to 9 months. If the treatment is not exactly followed, there is a risk the infection will not be eliminated, and the TB germs in that person can become resistant to the best drugs used for treatment.

Persons with HIV need to be screened regularly for latent and active TB by medical evaluation and skin testing. Some individuals may need additional tests including chest x-ray and sputum examination and culture for TB germs. Health care workers with HIV infection need to discuss with their physicians whether or not they can safely take care of patients who might have TB.

Q: My T-cell count is 425, and my viral load is 7500. I have never taken anti-HIV drugs. Do you think I should start taking them now?

A: You need to talk to your doctor. The decision to start treatment is based on clinical assessment, of which test results are only a part. I assume that you have no symptoms related to HIV such as fever, weight loss, unexplained diarrhea, thrush, or memory loss, and that there are no other specific conditions that could indicate a need for treatment such as thrombocytopenia (low platelet count), psoriasis, or HIV-related brain disease. If that is the case, then the other question to answer is what the T-cell count and viral load have been in the past. If these results are stable, then I would not typically recommend treatment at this time, but rather only close follow-up with blood tests and a doctor visit every 3 months. If the T-cell count is declining, then treatment should be seriously discussed even if you have a stable, relatively low viral load.

Q: My partner and I (both males) are positive and on anti-HIV drugs that keep our virus levels "undetectable." We are thinking about not using condoms anymore during sex. We are monogamous. What are the risks, if any, if we stop using condoms with each other?

A: To answer this question let's first consider the risk of HIV transmission between an HIV-positive partner and an HIV-negative partner, which is not your situation. The risk of transmission of HIV can be estimated only within a broad range. The risk of infection per act for anal intercourse is estimated to be higher for the receptive ("bottom") partner (closer to 1 out of every 10 acts) than for the insertive ("top") partner (about 1 out of every 100 to 1,000 acts). Oral sex also carries a risk of HIV transmission from pre-ejaculatory fluid ("pre-cum"), which may contain virus even when the blood viral load is undetectable. The direction of transmission in oral sex is most likely one-way, from the penis of the infected partner to the mouth of the uninfected partner. Transmission is more likely to occur if either person has a sexually transmitted disease or other genital inflammation, or if the insertive partner is uncircumcised.

Since you both already have HIV infection, the consequences of transmission are less likely to be life-changing. The primary risk is that of infection with a different strain of HIV, particularly if the new virus is resistant to the medications the other partner has been taking. Such "superinfection" or infection with a different strain has been suggested to occur, although how frequently that happens is unknown. In one case (presented at the 2000 Retrovirus Conference in San Francisco), a Canadian man appeared to contract a more virulent and drug-resistant strain of HIV from his partner. Another risk is that of transmitting other sexually transmitted diseases, which does not apply if both partners are monogamous. Finally, there may be an increased risk of prostate and urinary tract infections in men who practice insertive anal intercourse ("top") without condoms, regardless of their HIV status. You have to decide for yourself whether to use condoms in the situation you describe. One strategy might be to use condoms for anal sex but not for oral sex.

Gary Brewton, M.D., is a physician specializing in HIV medicine in Houston.


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