One Doctors' Approach for Preventing Opportunistic Infections

I am sending this to update you on the latest changes in my treatment approaches to HIV/AIDS.

OI's:	% & T - Cells:		Drugs and Dose:
PCP	14%	200	Bactrim DS, one/day or Dapsone 100mg/day with Trimethoprim 200 mg/day or Clindamycin 300 mg 2X/day with Primaquine 15mg/day. If intolerant to any of these, Mepron 750mg 2X/day
CMV	12%	150	Acyclovir (Zovirax) 800mg, two 3X day (4800mg/day)
MAI (MAC)	7%	100	Clarithromycin (Biaxin) 250mg 2X/day and Myambutol 400mg 2X/day
Toxoplasmosis	30%	400	If on Bactrim or Clindamycin for PCP, these are adequate. If not I use pyrimathamine 50mg/day with folinic acid (leucovorin), 5mg/day.

OI Prevention

In my practice aggressive opportunistic infection prophylaxis makes a dramatic difference in the rate of serious illnesses and in the survival rate in people with CD4s below 200 and/or 14%. I have been prophylaxing with the following drugs in patients with CD4s below the indicated levels (see chart at end of article).

In the past 5 years I have had only two patients with CMV retinitis and none with other invasive CMV infections. This includes patients with low CD4 numbers taking 800mg of acyclovir 6 times a day.

There has been only one "breakthrough" case of MAC in a patient on Biaxin plus Myambutol. However, when the MAC infection was treated by increasing Biaxin to 2000mg/day and Myambutol to 1200mg/day for 2 months the patient responded. One case of breakthrough cryptococcal meningitis, responded to an increase in diflucan to 600mg/day for weeks. I have seen a number of cases of mild PCP - symptoms: decreased appetite, mild to moderate shortness of breath and a more rapid pulse and heart rate. All have been treated on an office basis. I haven't seen any new cases of toxoplasmosis on this regime. Aggressive prophylaxes is primarily responsible for these results. However, all patients were also on low dose naltrexone which may also play a protective role.

The Public Health Service recently issued multiple OI prophylaxis guidelines in which prophylaxis for only PCP was recommended. I believe that the level of caution and conservatism reflected in these guidelines, while appropriate in the general practice of medicine, is very inappropriate with a life threatening disease such as HIV/AIDS. There are more than 250 patients with CD4's below 200 in my practice, yet there are few deaths, 7 or 8 per year.

Alternative Therapies

I have attempted in my practice to combine the most useful of conventional therapies with the most useful alternative therapies. I use practical observed results rather than any particular philosophy as the basis for clinical judgments. I have found that traditional Chinese medicine (with acupuncture and herbs) is often very useful, particularly in controlling some parasites, treating some symptoms, managing stress and maintaining good health. I view it as an adjunct to treatment with western drugs as I do the role of good nutrition, antioxidant therapies and aerobic exercise. The traditional herbal systems used in India, Tibet, Africa, the Caribbean, and Central and South American countries are likely to contain therapies of value for people with HIV/AIDS.

Alternative therapy approaches not tested by time and experience are less likely to be valuable and more likely to be risky. High dose intravenous vitamin C therapy and ozone therapy are 2 examples of risky therapy. Both appear to have been harmful to a number of my patients.

Overview

My goal is to keep my patients stable and symptom free. The long term goal is to keep them alive and well until a "slow cure" is available. To this end I prescribe low dose naltrexone to patients at all CD4 levels. I generally recommend acyclovir, 800mg 4X/day to control the activity of the 8 herpes viruses as cofactors. I treat hepatitis B and C, with St. Johns Wort to control these two viruses as cofactors. I use aggressive multiple OI prophylaxis as described. I treat minor infections aggressively as they can increase HIV replication. I avoid all vaccinations for the same reason. I use 3Tc & AZT in some of my more fragile patients despite my generally negative view regarding the widespread use of nucleoside analogues. But, this particular combination seems to be helpful. I think people should start saquinavir and ritonavir simultaneously to reduce resistance and mutations. (Check with your physician about combining protease inhibitors, at least 3 known PWA's died of renal failure on this combo.) I follow patients very closely. Careful, good medical management & early treatment of major/minor complications helps to maintain stability. Reinforcing a respectful & trusting doctor/patient relationship is an essential key to successful treatment of this difficult disease.