October 17, 2007
Following is the transcript of The Body's live chat on HIV treatment side effects, which took place on Oct. 17, 2007, at 4 p.m. Eastern Time. The chat was sponsored by Gilead Sciences, Inc., moderated by The Body's editorial staff and hosted by Dr. Joel Gallant. This transcript has been edited for grammar and clarity.
This is the tenth chat that The Body has moderated; to see transcripts of previous chats, click here.
Moderator: Thank you all for coming to TheBody.com's live, interactive chat on HIV treatment side effects!
A quick note before we get started: Please keep in mind that the information we provide in this chat is not meant to replace the attention or advice of a doctor or another health care professional. Make sure you consult with a qualified health care professional before making any dietary, drug, exercise or other lifestyle change!
OK, we're ready to begin! I'd like to introduce everybody to Dr. Joel Gallant, a professor of medicine and epidemiology in the Division of Infectious Diseases at Johns Hopkins University School of Medicine in Baltimore, and an associate professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health.
One of the most widely respected HIV physicians anywhere, Dr. Gallant is an active researcher and co-author of the seminal book Medical Management of HIV Infection, a guide for HIV health care professionals. We're honored to have him join us as today's chat speaker. Dr. Gallant, welcome!
Dr. Joel Gallant: Thanks! It's great to be back in the chat room.
Moderator: Alright, let's get this show on the road. Feel free to submit any questions you have for Dr. Gallant. Keep in mind that the topic of this hour-long chat is HIV medication side effects.
Question from anonymous: Having followed all the research, it seems to me that there is knowledge about how to stop the body changes that people with HIV on HAART [highly active antiretroviral therapy] experience. Aside from stopping d4T [generic name: stavudine; brand name: Zerit], what is known about the disfiguration that HIV meds can cause? I have thinning legs and a big waist, and although I switched four years ago, nothing has changed. NOTHING! -- Ken
Answer from Dr. Joel Gallant: Ken, both d4T and AZT [generic name: zidovudine; brand name: Retrovir] can cause lipoatrophy (fat loss). The way to avoid it is to avoid those drugs. You didn't say what you switched from and to, so I can't comment about your switch. Big waists are more difficult to evaluate. If the fat is visceral (inside the abdomen), then it could be a sign of an ongoing problem, or it could just be that the fat has nowhere else to go. On the other hand, if the fat is under the skin (if you can pinch it between your fingers), then it's probably just plain fat. Exercise and diet can help, regardless of the cause.
Question from anonymous: First of all, thanks for doing this Dr. Gallant. My question regarding side effects is: How can I manage the fatigue that I experience secondary to HIV medications, as well as other medications and conditions due to HIV? I'm so tired of being tired.
Answer from Dr. Joel Gallant: You shouldn't have to live with fatigue. If it's caused by meds, you may need to change [your regimen]. But don't forget to rule out the other possible causes: depression (the biggest), anemia, low testosterone, thyroid problems, etc.
Question from smartdog: What is the best cure for neuropathy?
Answer from Dr. Joel Gallant: There's no cure for neuropathy. The most important thing is to keep your viral load suppressed, but not use drugs that cause neuropathy (d4T and ddI [generic name: didanosine; brand name: Videx]). Rule out other causes (alcohol, diabetes, B12 deficiency, and thyroid problems). There are drugs that can help the symptoms, such as Neurontin [generic name: gabapentin; also sold under the brand name: Gabarone], Lamictal [generic name: lamotrigine], etc.
Question from Bill: I am taking Atripla [a coformulated drug consisting of: efavirenz, tenofovir and emtricitabine], and for the first time in 18 years, my viral load is undetectable and the regimen makes it very easy to stay on track. I have little, if any, side effects, but the very wild and vivid dreams that accompany it sometimes. Although these dreams can be quite entertaining, I have had a few that would really be classified as "NIGHTMARES." My question is: Will they subside with time or does this side effect continue? I have been on it for six months now.
Answer from Dr. Joel Gallant: Whatever side effects you still have at six months are the side effects that are going to remain -- things generally don't keep getting better after the first three to four weeks. So, you have to decide whether these are things you can live with or not.
Question from Rich: I have the same problem as Ken [with regards to body shape changes] ... but I try to eat low-fat, high-protein meals and I go to the gym daily. What else can be done? I also have ED [erectile dysfunction] and take Atripla. Is there help for this condition? I'm in my 50s.
Answer from Dr. Joel Gallant: I'd need to know what you have ... lipoatrophy, fat accumulation, or both. I already discussed what can be done for lipoatrophy. With fat accumulation, you have to find out whether it's really internal fat or just subcutaneous fat. If it's abnormal internal fat accumulation, there are some experimental therapies, such as growth hormone releasing hormone. You could look for clinical trials. Growth hormone can help, but the benefits are transient.
Question from anonymous: Which regimen has the least side effects? I am currently NOT taking HIV meds. But, I do take Seroquel [generic name: quetiapine] and imipramine [brand name: Tofranil] for depression/anxiety, so my liver is already somewhat taxed. I guess Sustiva [generic name: efavirenz; also sold under the brand name: Stocrin] is out, because of my mental health stuff. I'm new to meds and have no drug resistance. I'm 42, and have been HIV positive for 22 years.
Answer from Dr. Joel Gallant: Sustiva is not "out" unless you don't tolerate it. Many people with depression and anxiety do fine on Sustiva, as long as their mental health problems are well controlled when they start. And don't assume that your liver is "taxed," unless there's evidence of damage on blood tests. Your options for starting therapy are pretty much the same as they would be for anyone else.
Question from Liz: Is there anything I can do about blood sugar problems? I take Reyataz [generic name: atazanavir] and my doc's been saying maybe I should switch.
Answer from Dr. Joel Gallant: Reyataz is unlikely to cause blood sugar problems, so it may have nothing to do with your medications. Aerobic exercise, a low-sugar, low-carb diet, and weight loss can all help. But keep in mind that many of these metabolic conditions are common in HIV-negative people too, so they're not always caused by medications.
Question from Marshall: What can be done about gastrointestinal problems? I've been dealing and dealing, but I'm tired of running to the bathroom all the time. I'm resistant, so my doctor doesn't think I really have any other treatment options. Any recommendations for coping?
Answer from Dr. Joel Gallant: If you're taking PIs [protease inhibitors], fiber supplements can be extremely helpful (Citrucel [generic name: methylcellulose], Metamucil [generic name: psyllium; also sold under other brand names], FiberCon [generic name: calcium polycarbophil]). Don't be put off by the word "laxative" on the bottle -- fiber adds bulk to stool, which is a good thing whether it's too liquid or too solid. Most of my patients are reluctant at first, but once they try it, they won't go back.
Question from anonymous: I am doing just fine on my Combivir [a coformulated drug consisting of: zidovudine and lamivudine], but I have been reading about Epzicom [a coformulated drug consisting of: abacavir and lamivudine; also sold under the brand name: Kivexa]. How will I know if I will develop fat wasting if I stay on Combivir, and is there anything I need to ask my doctor about with regards to switching to Epzicom?
Answer from Dr. Joel Gallant: The AZT in Combivir is known to cause lipoatrophy. That doesn't mean it always will, but it's a risk. One approach would be to wait until you develop mild lipoatrophy and then switch. However, there are other problems with Combivir as well, which is why it's falling out of favor. I generally use Truvada [a coformulated drug consisting of: tenofovir and emtricitabine] or Epzicom rather than Combivir for many reasons. If you're going to use Epzicom, make sure you check your HLA-B*5701 test first.
Question from anonymous: I would like to know where, if anywhere, I could get help with the hump on my back and my sucked-in cheeks. I have been HIV positive since 1986, and this is really affecting my physical, spiritual and emotional well-being.
Answer from Dr. Joel Gallant: The sucked-in cheeks (facial lipoatrophy) can be treated with injections of Sculptra [generic name: poly-L-lactic acid; also sold under the brand name: New-Fill] or other face fillers, but it's rarely covered by insurance. You'd need to see a dermatologist or plastic surgeon. Ask about whether there are patient assistance programs. (And make sure you're not still taking medications that cause the problem.)
Buffalo humps can be treated with liposuction, but it's hard to get insurance to cover that procedure, and the fat sometimes returns. It's important to make sure you don't have insulin resistance or high cholesterol/triglycerides, which could make the problem worse. Growth hormone can also help, but it's very expensive, and the problem can return as soon as you stop the drug. You could also find out whether there's a growth hormone releasing hormone study in your area.
Question from sammy: I have been told that gabapentin can help with neuropathy. Are there any side effects to worry about?
Answer from Dr. Joel Gallant: The main side effect is excessive sedation. You can start at a low dose and work your way up if you need a higher dose.
Question from Bill: I know it is early, but does Truvada or Isentress [generic name: raltegravir; also known as MK-0518] cause any mental problems (i.e., weird dreams, etc.)? Also, I notice rashes from time to time. I am on the following HIV meds: Isentress, Prezista [generic name: darunavir; also known as TMC114], Truvada and Norvir [generic name: ritonavir]. Thank you for your time.
Answer from Dr. Joel Gallant: Truvada and Isentress don't generally cause mental side effects -- none of the meds you listed do.
Question from anonymous: My previous doctor started me on Videx 250 mg once a day, Viread [generic name: tenofovir] 300 mg once a day and Kaletra [a coformulated drug consisting of: lopinavir and ritonavir] 200 mg twice a day, three years ago. Since then, I have noticed issues with my joints and muscles. My new doctor suggests that I stop taking Videx as this could be the problem, also mentioning that doctors don't really like to use it any more due to its high toxicity level and side effects. Dr. Gallant, in your opinion, do you think Videx could be the cause of my new medical issues? Thank you.
Answer from Dr. Joel Gallant: What you're describing doesn't sound like neuropathy, which can be caused by Videx. It's true that Videx is less often used than other NRTIs [nucleoside reverse transcriptase inhibitors], but I don't think I can attribute your problems to that drug.
Question from anonymous: I'm taking Atripla and I am experiencing acid buildup in my stomach -- to the point where I can taste it on the back of my throat. It's like a metallic taste in my mouth. It gets so bad on an empty stomach that it keeps me awake at night. If I take a TUMS [generic name: calcium carbonate] or Rolaids [generic name: calcium carbonate], it goes away for a while but comes back. Can I eat something small, like some ice cream, beforehand to help my body ingest this better?
Answer from Dr. Joel Gallant: The only reason we tell people not to eat with Sustiva/Atripla is because it can increase the mental side effects. But if that's not a problem for you, it's OK to take it with food. It sounds like you have esophageal reflux, and you might need to take an H2 blocker or proton pump inhibitor -- ask your doc. Also, avoid big meals before bedtime.
Question from anonymous: Our daughter is 5 years old and has been on Kaletra, Epivir [generic name: lamivudine; also known as 3TC] and Retrovir since she was four. We aren't even sure which of her "poor" behaviors are the result of acting out and which are due to her HIV drug cocktail. She is up late, lacks attention, has night terrors and can't sleep. We adopted her from South Africa and got her at 3.5 years of age. Then she went on these meds. Even though she has responded well to the meds, we are wondering when it's appropriate to stop or switch her HIV treatment. What do you recommend?
Answer from Dr. Joel Gallant: It's hard to comment without knowing more about her viral load and CD4 count, but as a general rule, stopping therapy is rarely a good idea. I'm no expert in pediatrics, but the things you describe aren't typical side effects of these drugs in adults. You should talk this over with her doctor, but given that these problems are common in children and not common as side effects of the drugs your daughter is taking, I wouldn't be inclined to make a change if her regimen is successful.
Question from anonymous: Avascular neuropathy [note: the correct term is avascular necrosis; also known as AVN] is a sleeper impact of steroid use in PCP [pneumocystis carinii pneumonia] treatment. Is early hip resurfacing more appropriate than total hip replacement?
Answer from Dr. Joel Gallant: Steroids can cause avascular necrosis (not neuropathy), but they're not the only cause. It occurs more often in people with HIV infection, but we don't know whether that's due to HIV or to meds. Some of my patients with AVN have had hip replacement and some have had resurfacing. I leave that decision to the orthopedic surgeons.
Question from 3426TOR: Which medications cause mental problems, just to keep them in mind?
Answer from Dr. Joel Gallant: Mainly Sustiva (also contained in Atripla). Some people used to report depression with AZT, but that was back in the old days when we used higher doses. They may have been depressed because they were anemic, fatigued, and sleep deprived from taking it every four hours through the night!
Question from Rich: My doctor told me not to take Atripla unless two hours have passed since I last ate any food. Are you saying that I now do not have to wait the two hours? Sometimes I have eaten and then taken the pill one hour after eating and have had no side effects. It would help if I knew that I would still be OK by taking it on a full stomach. Thank you very much.
Answer from Dr. Joel Gallant: (This is in reference to the person who was having GI [gastrointestinal] problems on Atripla.) Like I said, you do NOT have to wait two hours. That's just advice we give in the beginning to minimize nervous system side effects. If you can take Sustiva/Atripla with food without problems, then it's fine to do that. Drug levels are HIGHER, not lower, when you take it with food, especially fatty food.
Question from MDBR: What are the main side effects of the new medication that was just approved last week? I think it is called Isentress.
Answer from Dr. Joel Gallant: As far as we can tell so far, the side effects of Isentress were "the same as placebo." In other words, if it has side effects, we haven't found them yet.
Question from anonymous: Could differences between generic drugs and name brand drugs be responsible for unusual side effects? Are brand-name drugs more pure and efficient? Thanks, Joseph.
Answer from Dr. Joel Gallant: In the U.S., generics get approved after they're shown to be equivalent to brand-name drugs, so I have no problem prescribing generic drugs here in this country. The quality control standards may differ from country to country, so I can't generalize to other parts of the world.
Question from anonymous: My CD4 count is 168 and I am on tuberculosis [also known as TB] drugs. How urgent is it for me to start ARVs [antiretrovirals]? I have taken the TB meds for a month now. What are the possible side effects due to taking both?
Answer from Dr. Joel Gallant: It's often a good idea to wait a couple of months before starting HIV meds if you're on TB meds. That's partly due to drug interactions and overlapping toxicity, but it's also to decrease the chances of an immune reconstitution inflammatory syndrome (IRIS) reaction, which can happen if you suddenly improve the immune system while still sick with TB.
Question from David53: Dr. Gallant: I am a 53-year-old, white male who has been positive since 1986. I have managed my HIV since that time, starting with AZT monotherapy immediately after my diagnosis. I have responded well to the new cocktails, though I have had to change them three or four times since 1996. Currently, my viral load is low or undetectable, and my CD4 count is around 600. Since January of this year, I have experienced chronic urticaria (hives) over most of my body. I have seen an allergist about the problem, and after many tests he suggests that it is either the HIV virus or my meds. I have eliminated EVERYTHING from my diet that could be an issue. I am currently on Lexiva [generic name: fosamprenavir; also sold under the brand name: Telzir], Norvir, Viramune [generic name: nevirapine], Epivir and Viread. I understand that Lexiva is sulfa-based, and I think as a child I was allergic to sulfa. My HIV doctor would rather not change my meds, as they are working well, and so I simply manage my hives with antihistamines. Have you ever heard of HIV or HIV meds as a cause for chronic urticaria? Many thanks for your contribution to this chat. All the best, David53.
Answer from Dr. Joel Gallant: Lexiva is the PI that may be most likely to cause rash or allergic reactions (Prezista is another). So if there's any question about whether this could be drug-related, a change in meds is something you could consider. Most of the other PIs aren't a problem.
Question from anonymous: Does HIV medication affect erectile dysfunction? Are more pills really the answer?
Answer from Dr. Joel Gallant: It's not entirely clear, but some people with HIV infection develop low testosterone levels, which could be due to HIV infection, medications, or both. If your testosterone level is low, then you need testosterone. If it's not, the erectile dysfunction is probably not related to your meds.
Question from anonymous: Fuzeon [generic name: enfuvirtide; also known as T-20] is associated with injection site reactions, and psychological resistance to self-injection can result in early treatment cessation. Is an oral formulation of Fuzeon likely to become available? If so, will it be available for re-use in those who stopped for reasons other than treatment failure?
Answer from Dr. Joel Gallant: There will be no oral Fuzeon any time soon. It's too large a molecule. However, there is one approved oral entry inhibitor (Selzentry [generic name: maraviroc; also sold under the brand name: Celsentri]), and we expect more to come.
Question from mike: Will the next class of HIV drugs have the same side effects as the protease inhibitors?
Answer from Dr. Joel Gallant: I mentioned the side effects (or lack thereof) of the integrase inhibitors already. We also know that, so far, maraviroc (the first CCR5 inhibitor) is pretty well tolerated as well. None of these drugs seem to cause much in the way of metabolic side effects, which we see with some of the PIs.
Question from lehma1br: I know a person who is taking Atripla. He said that the diarrhea and nausea were awful, and so now he changed his dosage from everyday to once every other day without consulting his physician. His counts were undetectable, and now they are very high again. Do you have any advice?
Answer from Dr. Joel Gallant: Your friend should stop playing doctor, because he's not doing a very good job. First, Atripla rarely causes either diarrhea or nausea, so he should have looked for other causes. But, even if it was the Atripla, going to every other day dosing was extremely dangerous from a resistance standpoint. He should have talked to his doctor, tried to find out whether it was really a drug toxicity or not, and if it was, he should have changed meds.
Question from thedude: What do you mean by metabolic side effects?
Answer from Dr. Joel Gallant: High cholesterol, triglycerides, or insulin resistance (which can lead to high blood sugar or diabetes).
Question from anonymous: Dear doctor, I too am taking Atripla once a day, and from the onset I have had a constant ringing in my ears. Is that a side effect to be expected????
Answer from Dr. Joel Gallant: No, it's not expected, but I suppose it could be from the Sustiva contained in Atripla. If it started when you started Atripla, then that's probably the cause. You'll have to decide whether it's something you're willing to put up with or not -- there are plenty of other alternatives. (Note that caffeine can make tinnitus -- ringing in the ears -- worse.)
Question from anonymous: Having never suffered from depression or any mental illness, I am amazed that five years after starting Sustiva I am still debilitated by the psychological side effects of this medication. I am no longer able to live this way (depressed, unable to concentrate, relentless dreams, constantly in a "fog"), despite an undetectable viral load and CD4 count of 475. I'm discussing other options with my doctor. My question is: Will my mind ever feel right again? I search and search for information on the long-term effects of Sustiva and can find nothing. Thank you for taking time to discuss the mental effects of Sustiva.
Answer from Dr. Joel Gallant: Five years??? You waited five years to discuss this with your doctor?!?! There are some people -- not many, but some -- who simply can't tolerate this drug, either because of intense short-term side effects or lingering long-term problems. It's often pretty clear within a month, since most Sustiva side effects have disappeared by then. If I have a patient who doesn't like the way he feels after one month of Sustiva, we switch to something else. If your problems are due to Sustiva, they'll disappear quickly within a few days of stopping the drug, and you'll wonder why you waited so long.
Question from anonymous: Hey there. I get very bad diarrhea (I'm taking Norvir, Prezista and Truvada). I was wondering what you can recommend to help reduce the symptoms.
Answer from Dr. Joel Gallant: Read my answer above, about the glories of fiber supplements. Take them twice a day when you take your meds.
Question from Yoyo: I'm newly diagnosed and worried about the damage HIV meds might do to my heart. Many of my (HIV-negative) relatives have suffered from heart disease. How much will HIV drugs increase my risk of developing heart disease? Are certain HIV meds better than others for people like me that are already at risk for heart disease?
Answer from Dr. Joel Gallant: HIV itself is probably a bigger risk to your heart than meds are, so the best thing you can do is treat your HIV. However, there are some meds that are less likely to increase your cholesterol than others. For example, Sustiva/Atripla, Reyataz, and now Isentress have less of an effect on cholesterol, and probably on blood sugar, than some of the other PIs.
Question from anonymous: Dr. Gallant: My generalist (not the AIDS specialist) suggested I take non-addictive Simply Sleep to counteract my vivid dreams caused by Atripla. Is it advisable? Is there danger of conflict with my Atripla? I know that it did eradicate the dreams entirely, therefore I am fully rested in the morning.
Answer from Dr. Joel Gallant: I don't know what's in it. Do you know what the active ingredient is?
Moderator: Dr. Gallant, in reference to the Simply Sleep question, its active ingredient appears to be diphenhydramine. The drug's produced by the makers of Tylenol.
Dr. Joel Gallant: In that case, it's quite safe. The only problem is drowsiness or "fogginess" in the AM, which can also occur with Sustiva/Atripla. But if you're not bothered by it, then it's OK to use.
Question from anonymous: My regimen consists of Kaletra and Lamzid (Combivir). I am doing well so far, but I have hyperpigmentation, which concerns me. I have read that the AZT in Combivir could be the problem. Please advise which of these medicines causes hyperpigmentation and what I can do to deal with the problem. My doctor does not seem to have a clue what to do. I am really worried and my confidence is very low, so much so that I avoid meeting people who know me, as they immediately notice the changes in my facial appearance.
Answer from Dr. Joel Gallant: When AZT causes hyperpigmentation, it's usually in the fingernails. It would be unusual for it to cause darkening of the face, but I won't say it's impossible. Keep in mind that some drugs can cause photosensitivity, which means they make you more sensitive to the effects of the sun. The solution for that problem is sunscreen. But if there's any question about a direct AZT effect, you could certainly switch to a different nuke [nucleoside reverse transcriptase inhibitor].
Question from jack coppola: How long does it take to notice any sign of lipodystrophy. I am on Atripla, I am a treatment-naive patient, I started in July, and I've noticed that my veins are more prominent on my hands and forearms. Is it too soon to see this kind of change in body fat distribution? I'm not sure that it is a "real change" or something I just didn't pay much attention to before.
Answer from Dr. Joel Gallant: Atripla shouldn't cause this problem, so maybe you're just looking at yourself too hard.
Question from anonymous: My cousin is taking a drug called Stalanev (a generic combination of stavudine, lamivudine and nevirapine available in the developing world) and she is developing boils all over her body, like five at a time. Could that be a side effect of her HIV meds, and what can she do to stop them? We can't go to the hospital lest the staff suspect her condition. We are staying in China and HIV is quite a taboo here. Please help before she loses hope.
Answer from Dr. Joel Gallant: I doubt that these boils are directly caused by either HIV or her drugs. It's more likely that she's colonized by the Staph bacterium, something that can happen in anyone. HIV infection could increase the risk or the severity of the problem, but the answer is to continue HIV treatment, not to stop it. (Keep in mind that I'm guessing about the Staph. There are other possible causes, but I've picked the most common.)
The treatment for Staph abscesses is to drain the pus, to use appropriate antibiotics (based on the results of a culture of the pus), and sometimes to try to rid the body of the organisms using antibacterial body washes and anti-Staph ointments.
You shouldn't assume that people will assume she's HIV positive because of these boils. She should go to a hospital if she needs to. But she's obviously getting medical care, since she's on treatment. Why can't she go to her doctor for some help?
Question from anonymous: I was recently diagnosed and treated for kidney stones, but there are still some small fragments remaining. During this six-month period, my creatinine levels elevated to a range of 1.3 to 1.7. Because of the kidney problems, as well as some occasional severe diarrhea, my doctors are considering changing my regimen from Norvir-boosted Lexiva and Truvada to boosted Reyataz and Epzicom. I understand that Truvada hits the kidneys hard, but I don't understand why he wants me to switch to Reyataz, which has liver-related side effects and also diarrhea. I don't want to switch meds that I have had good results with, and some friends have had problems with Reyataz. What do you think?
Answer from Dr. Joel Gallant: It makes sense to switch to Epzicom because of the kidney issues. It's also possible that boosted Reyataz might cause a little less diarrhea than Lexiva -- from a GI standpoint, it's probably the best tolerated of the PIs. On the other hand, "occasional severe diarrhea" is not common with any of the boosted PIs -- it's more common to have low-grade, chronic loose stools. One option would be to make one switch at a time, switching to Epzicom first (assuming you're negative for HLA-B*5701) to see how you do. Try fiber supplements to see if they help with the diarrhea. If the problem persists, you could then think about the PI switch.
Moderator: Dr. Gallant, could you take a minute to explain a bit more about what HLA-B*5701 is?
Dr. Joel Gallant: HLA-B*5701 is a simple blood test that can be used to predict whether you will get a hypersensitivity reaction [also known as an HSR] to abacavir [brand name: Ziagen]. If the test is positive, you should never take abacavir in any form (Trizivir [a coformulated drug consisting of: zidovudine, lamivudine and abacavir], Ziagen, Epzicom).
If the test is negative, then it is very unlikely that you will get an HSR. We always use this test now before starting abacavir.
Question from Billie: Will my insurance company pay for this HLA test?
Answer from Dr. Joel Gallant: They should. It's not very expensive (less than $100, compared with $1,960 for a Trofile assay). They may not even notice!
Question from anonymous: How does excess protein in urine affect a person? Why does the body excrete protein when it should be retaining it? How does protein loss affect the kidney?
Answer from Dr. Joel Gallant: You can lose protein in the urine for all sorts of reasons, but it's always a sign that something is wrong with the kidneys. The list of possible problems is too long to mention here, but if you've got protein in your urine, you need to be evaluated. Don't focus on the protein loss, but on what it's telling you about your kidneys.
Question from anonymous: At what CD4 count could a female taking HIV meds have children?
Answer from Dr. Joel Gallant: It's physically possible to have children at any CD4 count. The viral load has more to do with predicting the risk of transmitting the virus to the baby. That's not to say that the CD4 count isn't important -- a woman should optimize her health before having children, and she should be thinking about whether she'll be healthy enough to be a good mom. Someone with no CD4 cells probably has more pressing concerns than having to chase rugrats around the house.
Question from anonymous: Ten days ago, I started taking Atripla. On around the sixth day, I noticed a small blotch on my chest. The next day, it was covering my neck, arms and chest. My doctor said it was common for this to happen. He told me to stop taking the Atripla. Yesterday (day 9, second day with no Atripla) the rash had spread to almost my entire body: my face, arms, legs, thighs, private areas, back, everywhere. My doctor then put me on a prednisone [brand names: Prednisone Intensol, Sterapred] taper. Meanwhile, a good friend of mine is a doctor that specializes in HIV. He said that it doesn't make sense that my doctor is having me just stop Atripla without putting me on anything else for the time being. My CD4 cell levels are pretty low. What should I do about my treatment?
Answer from Dr. Joel Gallant: I agree with your friend. Rashes are common with Atripla (because of the Sustiva it contains), but it rarely requires stopping the drug. The rash generally goes away on its own without stopping or switching medications. The only time we recommend stopping therapy is if the rash is severe -- for example, if there is fever, peeling skin, or involvement of the mouth. Stopping Atripla without replacing it with something else can result in resistance to Sustiva and other related drugs.
It's possible that a prednisone taper will help the rash to go away faster, though you'll never know for sure, since the rash is going to get better regardless of what you do.
Question from anonymous: I have been taking Kivexa for about 18 months now. I have noticed since then several small bruises (they look like freckles) along my lower legs, but only along the tibia. Is this related? My counts are very good.
Answer from Dr. Joel Gallant: Kivexa (Epzicom to Americans) is unlikely to cause this problem.
Question from Flag04: When my wife was pregnant two years ago (HIV positive since 1990), her specialist put her on AZT, Truvada, Viramune, and Kaletra ... all of which were to help her AND help prevent transmission to the fetus. After our son was born (HIV negative), she was kept on the same drugs because it had brought her down to an undetectable viral load at [the time of our son's] birth. During that time, and into the present, she developed some horrible arthritic-type pains throughout her body: primarily her hands, neck, and the lower trunk of her body. A new specialist said that she was overdoing it on the meds and started her on just Kaletra and Truvada. Could the "excessive" meds have caused all the joint pain she's been experiencing in the last two and a half years? We've tested for Lyme disease, human parvovirus, and a number of autoimmune diseases with no answers. The docs just say "it could be the meds, but because of the HIV, the tests may not be accurate either." Whew ... thanks.
Answer from Dr. Joel Gallant: These aren't typical medication side effects. But assuming she has no resistance, I agree that the old regimen was overkill (especially for a pregnant woman, where we try to minimize drug exposure).
Question from ChrisTampa28: Could my Atripla be causing my liver enzymes to get real high and this pain that I have on my left side chest wall/rib area? Enzymes are 550. Started about a month ago. Always been normal. Negative for hepatitis. Have had an ultrasound, X-ray, cat scan, and blood work. They can't figure out what's wrong. My spleen is swollen and I'm always feeling tired and have this very bad pain. My CD4 is around 500 and I'm undetectable.
Answer from Dr. Joel Gallant: Atripla doesn't often cause serious liver enzyme elevation, but it can, especially in people with chronic hepatitis. Remember that the usual antibody tests don't completely rule out hepatitis B and C. If there's suspicion, you need PCR [polymerase chain reaction] tests as well (HCV RNA, HBV DNA). Since you have symptoms and very high enzymes, this isn't something you want to play around with. If the work-up is completely negative, it MAY be necessary to stop meds.
Question from anonymous: What can one do in advance to avoid gaining fat while on HIV drugs?
Answer from Dr. Joel Gallant: We know less about avoiding fat accumulation than we do about fat loss, because it's not entirely clear what it is or what causes it. My advice would be to eat well, do regular aerobic exercise, and treat insulin resistance or hyperlipidemia if you have them (or change to drugs that don't cause those problems).
Question from Dgathers2004: Is it safe to take a herbal colon cleanser while I'm on HIV meds?
Answer from Dr. Joel Gallant: Safe? Probably. Will it help you? Doubtful.
Moderator: I'm afraid we only have time to answer one more question. My apologies to all of you who have submitted questions that we couldn't get to today! We hope you'll use TheBody.com's "Ask the Experts" area at www.thebody.com/experts.shtml to get the answers to your questions.
Question from anonymous: For those of us who haven't started treatment, can you tell us which combination or combinations you find to be most side effect-free? Much appreciated!
Answer from Dr. Joel Gallant: With side effects, it's always a bit of a trial and error process, and what's great for some will be intolerable for others. I find Atripla to be very well tolerated for most people, for example, but a few can't get past the neurologic side effects. The PIs are much better tolerated than they used to be, and we're excited about raltegravir. The key is to stick with it until you find the regimen that works for you.
Moderator: And that'll do it for our live chat on HIV treatment side effects. Dr. Gallant, our deepest thanks for taking the time to answer everybody's questions!
Dr. Joel Gallant: It's been a pleasure, though my wrists are sore.
Moderator: Please feel free to bill us for the medical treatment. :) Incidentally, word on the street is that you've got a new book coming out?
Dr. Joel Gallant: Time for SHAMELESS SELF-PROMOTION: Keep an eye out for "100 Questions and Answers About HIV and AIDS" by Yours Truly, now available for pre-order on Amazon. You can read even MORE questions than you read on this chat!
Moderator: I'll be counting the days before I get my copy. :) Thank you again, Dr. Gallant!
To all of you who asked questions or took the time to join our chat tonight: Thank you for spending the past hour with us!