Complications in HIV used to mean opportunistic infections (OIs) as a result of AIDS.

Today, with HIV drugs protecting against OIs, attention turns to other threats:

• drug complications (see page 29)
• dangerous drug-resistant microbes,
• co-infections such as other sexually transmitted infections, hepatitis, and crystal meth addiction, and
• cancers

Not that AIDS and OIs are no longer a concern -- people are still dying because of them. Of special concern are people who cannot, or don't, access treatment, and the people who don't realize that they have HIV -- sometimes not until they have already developed AIDS. "The OI PCP [a pneumonia] is still a big problem, mostly because people aren't testing for HIV," said Matt Sharp, Director of Education and Advocacy here at TPAN.

People of Color

Waiting until HIV progresses before getting tested is more common in people of color. In fact, the great news of a drop in AIDS deaths since the appearance of powerful drug combinations in 1996 never give a breakdown -- the drop in deaths was huge for white people, but much smaller for black people. People of color had less access to treatment. That's in part, it seems, because of their own fears of the medical establishment.

Tracking Your Health

Maintaining health is all about keeping your CD4+ T-cells (T-cells) up and your viral load down. You might also have hepatitis or some other co-infection or condition that can speed up HIV disease progression.

Monitoring can help you prevent disease. Get regular lab work (see page 26) and watch out for co-infections.

Immune Reconstitution Syndrome

One "drug complication," ironically, is becoming ill when treatment revs up the immune system to the point where it begins to recognize invading microbes the way it should and starts to fight them. This is called "immune reconstitution syndrome." People can even require hospitalization when their immune system gets stronger and activates microbes in their body in order to kill them off.

Shingles is the classic example, a painful disease of reactivated chicken pox virus left over from childhood. Other conditions, such as syphilis, can also be speeded up following immune reconstitution.

Metabolic Syndrome

Another potential complication as a result of treatment is metabolic syndrome. It usually consists of high blood levels of cholesterol and triglycerides, which can lead to heart complications, and increased belly fat -- also dangerous to cardiovascular health. In HIV, this condition, which can manifest in different ways, is usually referred to as "lipodystrophy," because of the way that body fat changes. People can experience skinny arms and legs and facial wasting (loss of fat called "atrophy"), and increased fat on their stomachs and sometimes humps on their upper backs. Lipodystrophy is most commonly associated with the use of HIV protease inhibitor drugs, but occurs with some of the other antiviral medications as well.

MRSA

"MRSA" (pronounced "mersa") stands for "methicillin-resistant Staphylococcus aureus." Basically, this is a staph infection that can't be treated with normal therapy. MRSA can be dangerous.

The misuse of antibiotics has allowed stronger staph germs to develop, and thus begin to resist drug therapy (become drug resistant). Misuse, including getting doctors to prescribe antibiotics for colds (colds cannot be treated by antibiotics, but some doctors will give people a prescription anyway if they insist) and not taking all your pills, like when you're feeling better (this allows the bacteria to grow more powerful and become drug resistant -- at some point there may not be any more drugs available to treat a resistant infection).

A Positively Aware reader acquired MRSA while in the hospital (being treated for something else) when she stepped on the floor barefoot. This earned her an extra week in the hospital. Approximately one out of four of HIV-positive persons infected with MRSA will need to be hospitalized for it.

Hospital staffs are not good about washing their hands as often as they should, so don't shake hands with anyone. Tell them you just coughed or something. Try not to touch anything with your bare hands. Take antibacterial hand sanitizer with you (and use it), and wear socks.

MRSA has been seen out in the community, called "CA-MRSA" for "community acquired MRSA." Avoid sharing sports equipment and hygienic items like razors, towels, and dressings. Keep cuts and wounds covered.

MRSA causes skin infections that may look like a pimple or boil. The skin can be red, swollen and painful, with pus. People report that it looks like a spider bite.

Another drug-resistant infection on the prowl is MDR TB, or "multi-drug resistant tuberculosis." Again, drug-resistant diseases are harder to fight with therapies that are usually used. Newer, effective drugs may not be available. A stronger, more fearsome disease is being created.

STIs

Epidemics of sexually transmitted infections (STIs) have struck the gay community over the past several years, especially syphilis. The presence of another STI greatly increases the risk of becoming infected with HIV, and vice versa. Moreover, HIV tends to speed up disease from other infections.

Also, if someone is newly infected with both HIV and another STI, his or her risk of transmitting HIV becomes much greater. (People are much more infectious around the time of their own infection, for approximately six months afterwards. Because they may not have symptoms and may not know of their HIV infection, this group is considered responsible for many new infections in this country.)

Because HIV speeds up the development of syphilis disease, doctors see complications in just a few years that normally took decades to develop, disease like dementia or blindness. In Chicago, cases of syphilis went up 41% between 2004 and 2005, and the vast majority of infections were among men who have sex with men (MSM).

Syphilis symptoms include chancres (a painless ulcer at the site of the infection), enlarged lymph nodes, fever, malaise (generally feeling ill), and a rash.

Remember that oral sex also spreads disease. Gonorrhea can infect the throat and herpes sores on the mouth can spread to the genitals. Drug-resistant gonorrhea has also been seen.

Hepatitis

Hepatitis B and hepatitis C, both viral infections, complicate HIV disease and its treatment. Hepatitis B is transmitted sexually and through needle sharing. Hepatitis C is commonly transmitted through needle sharing. Its ability to transmit sexually is not clear, but some doctors are convinced that it is due to epidemics seen among HIV-positive gay men.

Crystal Meth

Much has been written about the effect of meth on HIV. Crystal has been linked to increased HIV infections, and is known to have profound negative effects on the brain. It's difficult to be healthy while addicted to meth.

Cancers

It's long been known that women with HIV are at greater risk for abnormal Pap smear results, which are an indication that cervical cancer may be present, and that MSM with HIV are at greater risk of Kaposi's sarcoma (KS). (You might see the word "malignancy," which means cancerous growth.)

Now, in the past few years, anal Pap smears are getting greater attention, with both positive men and women at greater risk of anal cancer, whether or not they have anal sex (but they're more at risk if they do). Positive MSM are at much greater risk of pre-cancerous changes than HIV-negative MSM.

The problem is that anal Pap smears are just beginning to be done, so few doctors have been trained to do them and no clinic standards have been established.

The American Academy of HIV Medicine provides an explanation of the procedure. The academy notes that specialists recommend the same frequency of testing as is done with cervical Pap smears. An anal Pap smear at the time of diagnosis should be done in MSM and women (plus a cervical Pap smear for the women). Repeat in six months. If results are normal, repeat once a year. If abnormal, proceed with anoscopy or colposcopy of the cervix. These are internal views using a teeny-tiny microscope. (It's recommended that HIV-negative MSM have an anal Pap smear every three years.)

PCP

Pneumocystis jiroveci is a fungus that can lead to pneumonia, called PCP. An inexpensive medicine helps prevent PCP in people with advanced disease. PCP symptoms include fever, dry cough, tiredness, increasing shortness of breath, weight loss, and night sweats.

Opportunistic Infections

Opportunistic infections (OIs) can affect people with AIDS (particularly if they're not on HIV therapy). They are considered "opportunistic" because they prey on people with weak immune systems, either by attacking at this stage or being much worse than would normally be seen. For more information, see "The Stalker Awaits" in the September/October 2001 Positively Aware and the OI prevention and treatment guidelines for people with HIV from the U.S. Department of Health and Human Services, 1-800-HIV-0448 (1-800-448-0448), www.aidsinfo.com.

Some OIs include

• bacterial pneumonia;
• candidiasis (commonly seen in the mouth, esophagus, and vagina);
• tuberculosis (TB), including mycobacterium TB;
• HHV-8, the human herpes virus 8, associated with Kaposi's sarcoma, a rare cancer;
• cryptosporidiosis, a parasite found in unclean water;
• microsporidiosis, from a common fungus, most likely acquired through animals or unclean water;
• toxoplasmosis, a disease that can cause meningitis (brain inflammation) or spread to other organs;
• shingles, a painful skin condition caused by varicella-zoster virus, a herpes virus;
• Mycobacterium avium complex (MAC), a bacterial infection;
• lymphoma, cancers involving white blood cells – AIDS-related lymphoma is also call non-Hodgkin's Lymphoma (NHL);
• bacterial enteric disease, severe diarrhea caused by three organisms (Salmonella, Campylobacter, and Shigella); and
• human papilloma virus (HPV), common sexually transmitted infection that can cause genital warts and may lead to cancer and infertility.

Monitor

Monitoring your health and using prevention techniques can help you avoid complications. There may even be free testing and treatment for some of them near you. Check your local health department to see what STI services are available.