GayHealthBlog.com

ASK THE DOC: HIV med - Double Dose or No Dose?

Help! I am taking the one a day HIV med but I couldn't remember if I took it last night, so in  a panic I took one late this morning, just to be sure, but should I have waited? Is there a potential problem if I happened to double the dose? I figured it would be better than maybe missing one, but did I do the right thing?

No worries. One extra dose will not hurt you and it is better not to miss an entire day. To avoid similar confusion and anxiety in the future, try to organize your pill taking in a way that this doesn't happen again. For example, put the medication by your toothbrush and take it after you brush your teeth. Or put it in that area first thing in the morning, and take the pill that night. Or you can try some other variation on that theme, whatever works best for you. Good luck! -- Susan Ball, MD

ASK THE DOC: My sex life is a disaster!

I'm HIV positive and on the one-a-day medication and doing and feeling well. That said, my sex life is a disaster! I want to have safer sex but other positive men I've met simply are not interested in safe sex. I've met some very nice negative guys, but just wonder what the risk is for them having safe sex with me. Does the fact that my viral load is 'undetectable' lower the risk for my partner? I'm too young to be celibate, please help.

It's frustrating to hear that you are having such a hard time getting partners to practice safer sex. As a clinician and care provider for people with HIV I can't tell you how sad it is to see a young man come in who is newly infected with HIV. This is PREVENTABLE. And as you know, despite the ads making everyone look fit and fabulous, being HIV positive is a drag. So you deserve lots of praise and support for your efforts to keep your partners safe. 

What is also so crucial these days is the huge pile of random STDs that are growing every day. People are coming in with herpes and syphilis and gonorrhea and warts and all kinds of stuff. Most are treatable, sure, but most also increase the likelihood of HIV transmission. Don't give up on being safe with your partners. Get adventurous and wild and use flavors and lube and whatever else it might take but be of the mindset that sex can still be very awesome with a condom. You may be in a minority but you can have a clean conscience. Keep up the strong work! -- Susan Ball, MD

  

ASK THE DOC: How much higher can my T-cell count go?

A year ago I found out I was HIV positive. After taking the vitamins my doc prescribed, my T-cells have been over 400 ever since. How much higher can my count go, and what kind of T cell numbers does a non-infected person have? I'd like to get to 600 (it's my goal). Any advice?

In our lab at the hospital a normal T-cell count is 588-1202. Most non-HIV-infected patients will have T-cells in that range. If your HIV infection is only a year old or so you may have a T cell count that stays in the 400s for years. It may go higher. If we knew of any ways to make the CD4 cell count go higher without starting antiretroviral therapy (ART) we'd be very happy. Eating well, exercising, not exposing yourself to more virus, all these things are good for you but there are no known ways to effectively boost this part of your immune system (many health food articles to the contrary). If you've been HIV positive for years before actually getting diagnosed it may be that your T cells will not remain at 400 but may sink a bit.

Recent changes in the guidelines for starting patients on therapy for HIV recommend that physicians offer treatment to patients whose T-cell counts are between 350 and 500 whereas previously it was generally agreed that patients should wait to start (unless they developed some HIV-related illness) until the T-cell dipped below 350. Based on some large studies that support earlier treatment, your physician might recommend that you get started on medication for HIV now. This is a very important decision and each individual needs to review all the pros and cons carefully with their doctor.  Had you written this letter a year ago I'd be telling you that your are doing great and won't need meds for a while but today I'm writing with the suggestion that you and your doctor talk together about whether you are ready to start treatment.  The guidelines are not rules, but they are based on good data and lots of smart people with lots of experience trying to advocate for the best outcomes for patients with HIV. Good luck. -- Susan Ball, MD

ASK THE DOC: Should I take a Probiotic?

  I'm considering taking a Probiotic and my concern is a negative interaction with the drug Atripla. Is there any know issue with people taking Atripla and a probiotic?

I consulted the nutritionist that I work with and neither of us have heard of any adverse interactions of probiotics with Atripla. Keep this in mind, however: Probiotics are not controlled substances, and do not pass through the FDA regulatory board so my knowledge is strictly limited. -- Susan Ball, MD

ASK the DOC: When to start HIV meds, and what about Vitamins?

I'm a 27 year old male, I have had HIV for about 5-6 years but just got clean from crystal meth after seeking treatment this summer. I am serious about taking care of myself now, but the whole thing is very overwhelming and confusing. As of July, my CD count is 294, and I am not currently on meds. I did another blood test recently and they said depending on the results they may start me on meds next month. In the meantime, I feel very tired and rundown all the time, and I cannot put any weight on at all.

 I am wondering about vitamin supplements I can start taking to help battle the HIV in my body. What are some essential ones I should start taking? I currently take 1-2 Centrum multi-vitamins daily, and also 500 mcg of B-12. I heard that HIV patients should have at least 2,000 mcg of B-12 daily. Is this true, should I up my dose? Thanks for your help!

Congratulations on getting clean and getting yourself to focus on taking care of your health. The current guidelines for starting antiretroviral therapy indicate that a T cell count of 350 or less is when a patient should start (as long as they are ready). Some clinicians would start earlier and we could argue that given your weight troubles and feeling tired you should get started regardless of what your next counts show.

You might also ask your provider to check your testosterone level (I have made the assumption that you are a male) which many times is low in patients who are HIV positive and could account for some of the fatigue.

As far as vitamins go, what I tell my patients is that there is a lot of alternative medicine out there and not all of it is accurate or valid. I am very supportive of people finding good diet and vitamin regimens with the aid of a knowledgeable naturopath - provided that it doesn't interfere with the medical management recommended by the doctor. You also have to be quite careful not to go overboard on the prices. Sometimes I'll have a patient who is spending more than $100 a month on vitamin supplements and I just am not sure that is that helpful.

I think, for the most part, any excess vitamins that are ingested are excreted in the urine but 2000 mcg a day of B-12 sounds a bit much. Sorry I can't be more helpful with the vitamin specifics but there are lots of dietician/counselors out there who know much more than I do.

Good luck. -- Susan Ball, MD

ASK the DOC: Will HIV meds keep me healthy forever?

Im a 24 year old gay man, and I just started a once a day HIV med, but am being treated at a public clinic and didn't ask enough questions of the doctor. I'm wondering how long I will have to stay on medication and if I will ever have to take more than one pill in the future? Will I be able to stay heathy?

Given that you are asking these questions, your health care provider is really not spending nearly enough time with you! These are important questions and a lot depends on your comprehension of the answers. As of today, this moment in our knowledge of HIV treatment, once someone starts on medication, it's forever. Ideally your numbers are going to improve, your T cell count go up and your viral levels fall to undetectable.

If you take your medication incorrectly, skip doses or stop altogether, those numbers are going to revert very quickly. If you are on Atripla, which is the only antiviral regimen so far that is one pill once a day, that is a great regimen and it works extremely well and will work for many years provided you NEVER miss a single dose. If you start missing the virus could become resistant to the medication and you'll need a different regimen. No other regimens are as simple as Atripla.

But yes, you can stay very healthy for many years taking medication for HIV.

Next time you see your provider you should insist that they spend a little more time with you going over this stuff. It's really important that you feel comfortable and knowledgeable about what you're doing. Good luck!
-- Susan Ball, MD

ASK THE DOC: HIV and weight loss...

I'm an AIDS patient with CD4 count of less than 100. I haven't started treatment yet but plan to start in coming days. I am experiencing chronic dysentery, some skin related problems and weight loss. I'm most worried about the weight loss. It's the most horrible thing.

Could you suggest some ways to stop the weight loss and get a few extra pounds on my body?

If you haven't started treatment yet and have T cells of less than 100 it is not surprising that your symptoms include diarrhea, skin problems and weight loss. I wonder why you are waiting to start meds as your HIV sounds like it is wreaking havoc with your poor body. Your T cells need some help!

Getting on meds will drive down the level of virus in your body, allow your immune system a reprieve and you will start to feel better. Occasionally, in very immune-suppressed people, starting medication might make them feel worse for a brief time. They might experience fevers or exacerbation of some symptoms. This is called immune reconstitution and it is a sign that the immune system can mount an inflammatory response once again. Staying on meds is the key and these symptoms resolve. You may not experience symptoms from immune reconstitution, there's no way to predict. But you are playing a kind of roulette denying your system the help it needs to fight the virus. As far as weight goes, it is almost a certainty that if you get your viral load down you will start to regain the weight you've lost. Please give yourself a chance and start fighting the HIV. Good luck.

-- Susan Ball, M.D.

ASK THE DOC: We're both HIV-positive, why use condoms?

I'm HIV positive and dating other HIV positive guys. I'm open to using condoms, but so many of my dates want to bareback, and I've been told by my doctor to have safer sex. I've been doing very well on treatment and he says I could get a bad strain. Is this accurate?

Your doctor is right. It seems there is a lot of anonymous sex going on out there and people are not using condoms, thinking that since everybody's HIV positive there's no risk. But there is a LOT of risk. There is the significant risk of transmitting other STDs, of which there are many and all seem to be on the rise (herpes, syphilis, gonorrhea, warts, chlamydia, even Hepatitis).

The risk in terms of HIV is a bit more vague in that if two people have undetectable viral loads it's unlikely that they are going to transmit virus to each other. But if one person has detectable virus they can transmit it to their partner. The risk is that the transmitted virus could cause problems in the new host, either because of resistance or because of the possibility of slight genetic variance which has negative impact. Even for people with undetectable virus I counsel condom use as we know that there are reservoirs of virus in places that we don't measure (lymph nodes, spinal fluid, seminal fluid). So undetectable viral load doesn't mean no risk, it just means low risk. I hope this is helpful to you.-- Susan Ball, M.D.