Questions from Readers and Answers by Medical Experts
on Treatment and Care for HIV and AIDS

My doctor is has recommended that I switch from my current PI-based regimen to an NNRTI Sustiva-based regimen. I have heard that Sustiva is responsible for causing nightmares, sleeplessness and extreme agitation and depression, so I am concerned about using the drug. What is the likelihood that I will experience these side effects?

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

There is no way to tell in advance which patients will experience these or other central nervous symptom side effects from use of Sustiva, nor how long these adverse effects might be experienced by any individual patient. However, it most instances the CNS side effects associated with Sustiva diminish or even go away altogether within a couple weeks after initiating treatment with the drug. And many people using Sustiva never experience these side effects at all. Talk to your doctor about the possibility of a "trial run" with the drug to see if you can tolerate it without too much trouble. If Sustiva doesn't work for you, ask your doctor about the pros and cons of using nevirapine (Viramune) instead.

I AM A 37 YEAR OLD BLACK MAN WHO HAS BEEN HIV POSITIVE FOR THIRTEEN YEARS. BY GODS GRACE I HAVE YET TO SUFFER THE HORRIBLE EFECTS OF THIS VIRUS. I HAVE NEVER BEEN HOSPITALIZED NOR SUFFERD ANY SERIOUS COMPLICATIONS. AFTER A VERY STRESSFULL YEAR AND AN EMOTIONAL BREAKUP WITH MY PARTNER OF 13 YEARS, I SUFFERD AN ESTREME AMOUNT OF STRESS THAT HAS CAUSED MY T CELLS TO DROP BELOW 200.

MY QUESTION IS, IS THERE ANY OTHER ALTERNATIVE OTHER THAN THE ANTI VIRAL MEDICATIONS? I HAVE NEVER TAKEN MEDICATIONS DURING THE 13-YEAR PERIOD UNTIL THE DROP IN MY CELLS OCCURED OUT OF PANIC AND FEAR I RELUCTANTLY BEGAN HIV ANTIVIRAL TREATMENT. I HAVE TWICE STOPPED TAKING THE MEDICATION BECAUSE THE SIDE EFFECTS IS SO UMBEARABLE FOR ME, SO BAD THAT I'D RATHER SUFFER WHATEVER CONSEQENCES THAN SUBJECT MYSELF TO THE DEBILITATING EFEECTS OF THIS MEDICINE. IS THERE ANY WAY THAT I CAN RAISE MY T CELL COUNT AND LOWER MY VIRAL LOAD WITHOUT THE HARSH EFFECTS OF THIS MEDICINE OR DO I HAVE TO ENDURE THIS WITH THIS MEDICINE? THANK YOU FOR READING. CONFUSED IN NY.

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

There is no known method or treatment outside the use of antiretroviral therapy that can slow or halt the decline in CD4 T cell counts and the increase in HIV viral load that you are experiencing. With a CD4 T cell count of 200, you are at a critical stage in the progression of your HIV disease. Falling below a CD4 T cell count of 200 dramatically increases your risk of infection with a variety of HIV-related opportunistic infections, some of which are life-threatening.

In addition to being life-threatening, these infections cause severe illnesses and morbidity, and take a horrific toll on the mind and body. Once present, successful treatment for these infections can be difficult, and the side effects of the drugs used to treat them are very hard on patients. On the other hand, use of anti-HIV therapy can raise your CD4 T cell count and decrease your HIV viral load, which will ward off your susceptibility to most of these infections.

You should urgently consider starting anti-HIV therapy as soon as possible to avoid falling into the grip of these opportunistic infections, which could significantly decrease your survival time.

There are now several available anti-HIV regimens that do not cause debilitating side effects for most of the people who use them. The better the health of individuals when they start these medications, the fewer problems they have with unwanted side effects.

I urge you to see a specialist in the treatment of HIV disease and to discuss with him/her which anti-HIV regimen would likely be best for you, and I urge you not to delay consideration of starting such therapy.

Good luck!

I am a 32 yr old black female in the St Louis. MO. I recently had a 2 month sexual relationship with my daughter's father. For the most part our relations were unprotected. Our Last encounter was June 14th. After which time I found out he was sleeping with @ least 2 other black Women.

I had 2 HIV test June 28 & 29. Both were negative. He is a career criminal. He was released from a MO prison July of last yr. I asked his status. & he SAID he was negative. MÒ mandates HIV testing for all prisoners upon release. Can I assume that the 2 tests I took were conclusive? What are the odds that my 12 week test will come back negative as well -given the stats for black Women in the US? Can I test 6 weeks post last possible exposure & be done with testing?

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

To be certain about the reliability of your previous negative test results, the CDC recommends testing 6 months (24 weeks) following your last exposure to the virus. If the 24-week test result is negative, then you can rely on its validity.

At present, for positive results to the rapid HIV test, post exposure to a HCW, our facility is offering Comibivir and Crixivan. Have there been any changes to the guidelines for PEP since 2005?

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

The September 30, 2005 guidelines are the most recently published CDC PEP recommendations for health care workers of which we are aware.

In those recommendations, the CDC says that the majority of HIV exposures will warrant a 2-drug regimen, using two NRTIs or one NRTI and one NtRTI. According to the CDC document, combinations that can be considered for PEP include ZDV and 3TC or emtricitabine (FTC); d4T and 3TC or FTC; and tenofovir (TDF) and 3TC or FTC.

You definitely should consult with the experts at your area regarding their best medical judgment on this issue, as expert opinion on prophylaxis and treatment for HIV infection is constantly changing based on new clinical data and the approval of new antiretrovirals.

Use of Kaletra-, Sustiva- , or Viread-based 2-drug regimen might be preferable to a ZDV- or d4T-based double combination (fewer side effects and more potency).

Since 1995, the CDC recommendations for first-line treatment of chronic HIV infection favors 3-drug regimens such as Kaletra (plus Combivir) or Sustiva (plus Combivir) or Sustiva plus Truvada (tenofovir/emtricitabine).

Can HIV be transmitted through deep kissing? My partner is HIV positive, and has chronic psoriasis. Should I take precautions against this as well?

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

Psoriasis is not a transmittable disease.

Open-mouth kissing is considered a very low-risk activity for the transmission of HIV. However, the Centers for Disease Control (CDC) takes the position that prolonged open-mouth kissing could damage the mouth or lips and allow HIV to pass from an infected person to a partner and then enter the body through cuts or sores in the mouth. Because of this possible risk, the agency recommends against open-mouth kissing with an infected partner.

Can a person with aids qualify for the shingles [herpes zoster] vaccine? I have seen people suffer horribly from this chicken pox virus and would very much like to get vaccinated? I currently have a reconstituted immune system with a CD 4 count of 620 and an undetectable viral load. Thank you.

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

The CDC has advised that persons with HIV/AIDS should NOT receive the shingles vaccine due to their weakened immune systems. See also http://www.cdc.gov/nip/publications/VIS/vis-shingles.pdf

What is HIV-related immune reconstitution inflammatory syndrome?

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

Following are 3 HIV and Hepatitis.com articles on this syndrome:

To Avoid Immune Reconstitution Inflammatory Syndrome (IRIS), Patients Should Initiate HAART Before CD4 Count Falls Below 100 Cells

Toward Defining the Incidence, Risk Factors and Long-term Outcome of a Unique, HAART-related Disease: Immune Reconstitution Inflammatory Syndrome (IRIS)

Kaposi's Sarcoma-associated Inflammation Seen after HAART

More Articles on this syndrome...

I understand cotrimoxazole used prophylactically keeps at bay most opportunistic infections that accompany HIV infection. How safe is it when used in expectant mothers considering that it can give rise to icterus jaundice? Would it still be useful when used to treat say URTI?

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

The following information is drawn from the cotrimoxazole product label. Be sure to discuss this information with your doctor and, if necessary, ask for referral to a specialist with experience in managing HIV positive, pregnant women.

SMX-TMP (Bactrim; Septra, etc) is in FDA Pregnancy Category C. There are no large, well-controlled studies on the use of SMX-TMP in pregnant women. No adverse effects on fertility or general reproductive performance were observed in rats given oral dosages as high as 70 mg/kg/day trimethoprim plus 350 mg/kg/day sulfamethoxazole. In rats, oral doses of 533 mg/kg sulfamethoxazole or 200 mg/kg trimethoprim produced teratologic effects manifested mainly as cleft palate. The highest dose that did not cause cleft palate in rats was 512 mg/kg sulfamethoxazole or 192 mg/kg trimethoprim when administered separately. In some rabbit studies, increased fetal loss was associated with trimethoprim doses 6 times the human therapeutic dose. Because both sulfamethoxazole and trimethoprim may interfere with folic acid metabolism, SMX-TMP should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Contraindications

SMX-TMP is contraindicated in patients with a known hypersensitivity to trimethoprim or sulfamethoxazole or sulfonamides and in patients with documented megaloblastic anemia due to folate deficiency. It is also contraindicated in pregnant patients at term and in nursing mothers (sulfonamides pass the placenta, are excreted in the milk, and may cause kernicterus) and in pediatric patients less than 2 months of age.

SMX-TMP shares the toxic potentials of sulfonamides and trimethoprim. Rarely, fatalities have occurred in patients receiving sulfonamides secondary to severe drug-induced reactions, including Stevens-Johnson syndrome, toxic epidermal necrolysis, fulminant hepatic necrosis, agranulocytosis, aplastic anemia, and other blood dyscrasias. Such fatal reactions also have been reported when sulfonamides were used in fixed combination with other drugs (e.g., trimethoprim or erythromycin). Sulfonamides, including the SMX-TMP combination, should be discontinued at the first appearance of skin rash or any sign of adverse reaction.

How soon are the results of an HIV antibody test to be considered conclusive?

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

Six months (24 weeks) after exposure to the virus

In India, people with HIV are given ARV drugs only if their CD4 count is below 200 (in the public sector). There are no viral load tests done. I realize that the key to longevity is adherence to the drug regiment. However, what is the universally recommended time when ARV drugs should be given to people with HIV?

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

Following are the most current US Public Health Service guidelines regarding when to initiate therapy in HIV positive individuals:

• Antiretroviral therapy is recommended for all patients with a history of an AIDS-defining illness or severe symptoms of HIV infection regardless of their CD4+ T cell count.

• Antiretroviral therapy is also recommended for asymptomatic patients with <200 CD4+ T cells/mm3.

• Asymptomatic patients with CD4+ T cell counts of 201-350 cells/mm3 should be offered treatment.

• For asymptomatic patients with CD4+ T cell of >350 cells/mm3 and plasma HIV RNA >100,000 copies/mL, most experienced clinicians postpone therapy, but some clinicians may consider initiating treatment.

• Therapy should be deferred for patients with CD4+ T cell counts of >350 cells/mm3 and plasma HIV RNA <100,000 copies/mL.

Maybe you can shed some light on my situation. I recently found out after a liver biopsy that I have stage 1/2 liver disease progression.

I am HIV + for about 3 years. For the first 2 years of my HIV infection I was on Viramune and Truvada with a T cell=450 and VL=undetectable. Last year I was infected with syphilis which was taken care of but at the onset of syphilis my liver enzymes (ALT/AST) rose to about 150/300) and all medication was discontinued. For the past year my liver enzymes have still been consistently 2/3 times the normal level. I am not a big drinker or drug user and no medication at all. I've had a CT SCAN and now a liver biopsy. My platelet count has also dropped a bit in recent months to about 80.

I DO NOT have HEP A/B/C although I was infected with HEP A/B about 10 years ago but no recurrence just antibodies... They've done several tests over the year for HEP C which has been negative. My T cells and VL off meds for the past year are around 340 T cells and VL=50000.

The DR. has done many tests including cancer etc. and doesn't know exactly what the answer is yet but thinks that the HIV itself might be cause this. The liver biopsy shows Level 1/2 damage. I have mild fullness in my upper right quadrant and back which is the most bothersome thing. He has recommended we start HAART again to see if this alleviates the issue.

So my questions are I guess:

Liver 1/2 stage progression. What does this mean exactly in terms of my long term health? Will this heal itself or am I screwed?

This specialist has been pretty thorough (as has my regular Dr) with tests and has ruled out a lot. He also has said it is nothing I am doing as I am working out etc....What are you thoughts?

 Answer by Mack Mitchell, MD  
Dr. Mitchell is Director of Gastroenterology at the Johns Hopkins Bayview Medical Center,
Baltimore, Maryland and Associate Professor of Medicine, The Johns Hopkins University School of Medicine

Unfortunately, this is a situation where examining the liver biopsy would be helpful. In the absence of another specific cause based on blood testing, the liver biopsy, scans and perhaps other tests are needed to determine the cause of the problem. Without that information, there is no way to know what the natural history will be. HIV per se is not a cause of liver damage. However, there are opportunistic infections that can infect the liver and there are other problems such as fatty liver that can also damage the liver. You will need to discuss that with your doctor.

How can one partner be HIV positive while the other one is negative and yet they are indulging in unprotected sex together?

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

This does not occur very often. Usually the negative partner will become positive after repeated exposure to HIV. However, some individuals' immune systems are able to resist HIV infection in spite of multiple exposures without barrier protection. The mechanism is not yet understood.

I am 54 years old and recently was diagnosed with HIV. My CD4 cell count is 477 and my viral load is 9000 copies. I am trying to gather data and understand what the average longevity might be for someone with HIV at my age and with my current test results. There is evidence that I had hepatitis C in the past. I was not diagnosed as a result of illness (this was a blood test for a life insurance purchase). I have been reading that the current medications are less effective in persons my age than in younger people.

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

Current antiretroviral medications may be somewhat less effective in some older persons compared to younger individuals. However, the differences are not significant enough to warrant your not using them. Given your CD4 count, you should do well. Ideally, you would want to get your viral load below 50, or at least below 400 copies. There is no way to predict survival times for a specific individual, but the outlook for you is promising as long as your viral load and CD4 counts remain stable.

I am a 38-year-old female. I just found out that the male partner I have been with for four years has full blown AIDS. I tested negative for HIV a year ago when I was pregnant with our daughter. We have 2 children together and have had unprotected sex for almost 3.5 years. I have been tested again and am awaiting the results.

My partner was told that his CD4 cell count is 15. What are his chances of survival, and where can I get more information on universal precautions for home care? I am concerned not only for his health and well-being, but also that of our children and myself.

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

You should make an appointment with your doctor or with an AIDS-knowledgeable physician to discuss your personal situation. If you are no longer having unprotected sex, then there is little risk for infection from your partner. Casual contact is not risky -- touching, kissing, hugging, sharing eating utensils, etc, carries no risk for you or your children. The major risk would be blood-to-blood contact or vaginal or anal sex without a condom.

With a CD4 cell count of 15, your partner has late-stage AIDS and is vulnerable to a variety of life-threatening infections. He should be under the care of an HIV-knowledgeable physician, on anti-HIV therapy, and on treatment to prevent opportunistic infections, which could make him severely ill and threaten his survival.

I have a question about the new combination pill, Atripla [efavirenz + emtricitabine + tenofovir]. What is the bioavailability of the various drugs in the composite pill? Is it the same as taking the individual drugs as separate pills?

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

The effectiveness of the combination of these three drugs in a fixed-dose combination was demonstrated in a 48-week clinical trial with 244 HIV-infected adults. One Atripla tablet was bioequivalent to one 600 mg Sustiva (efavirenz) tablet plus one 200 mg Emtriva (emtricitabine) capsule plus one 300 mg Viread (tenofovir) tablet following single-dose administration to 45 fasting healthy subjects. You may want to look at the Atripla product label to gain more insight into this issue. Click to view: Labeling [50-page PDF File]

I received a blow-job from a girl who I know has had multiple sexual partners. During the encounter I contracted chlamydia. I tested negative for HIV after about 75 days. Should I consider this to be conclusive that I don't have HIV? Please help. I'm really stressing out.

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

The risk of HIV infection from oral sex is very remote, especially among heterosexuals. If you remain concerned, then get an HIV antibody test at least six months after the possible exposure. That result will rule out any possibility of a false negative result from earlier tests.

My CD4 T-cell count is 29 and my HIV viral load is 8,500 copies. I take a regimen containing Epizcom (3TC/abacavir combination pill) Kaletra (lopinavir/ritonavir), and Invirase (saquinavir). I also take levothyroxine for a thyroid condition, Valtrex (valacyclovir) for herpes, dapsone for PCP, fluconazole (Diflucan) for thrush, spironolactone to reduce water retention, Creon 10 (pancrelipase) to improve absorption of fat, and a daily vitamin/mineral supplement.

My viral load continues to increase and my T-cells continue to drop. Now I am starting to experience muscle spasms in my lower legs and the bottom of my feet. I weigh 128 lbs and feel that I have no energy. I tire easily. Previously, I used to go to the gym, but now I lack the energy. Are any of my medications causing these side effects? What can I do? Your guidance is appreciated.

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

It's not possible for me to offer any specific advice or recommendations regarding your drug therapy. However, I can comment on your situation in general.

When viral load remains detectable on a HAART regimen, you should discuss with your physician why this might be happening. Perhaps he/she would then recommend a different regimen that might be more potent and have fewer side effects.

Anti-HIV drugs can often cause a sense of tiredness and fatigue. They can also cause muscle pain. Be sure to let your doctor know what symptoms you are experiencing, and ask if these symptoms could be related to your current therapy. There may be therapeutic alternatives that do not cause the side effects you are experiencing and that also might be more potent than your current drugs.

I would urge you not to give up on the gym unless you are unable to do any sort of physician exercise. Don't overdo it, but continue with an exercise program that does not wear you out. Aerobic exercise (walking on the treadmill, etc.) is good for you, and a limited amount of weight training can also be beneficial. Many people find that moderate exercise actually increases their energy level.

I am coinfected with HIV and HCV. I've been on Sustiva (efavirenz) plus Truvada (tenofovir/emtricitabine) for almost one year. I missed a dose of my meds for the first time yesterday. I usually take them at 8 p.m., but didn't do so until noon the next day. Was that too late? Should I have waited until 8 p.m. the next day? Is this cause for alarm with regard to drug resistance?

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

Taking your regimen at noon the next day after skipping one dose will not harm your health or cause resistance unless you continue to miss doses. Try to stay as close to 100% adherent as possible. Congratulations on having found a successful regimen. Keep up your vigilance about staying adherent!

I am co-infected with HIV and HCV. I was diagnosed one year ago at age 49. My CD4 count was 248 cells and my HIV viral load was 36,000 copies at that time. I've been on Sustiva (efavirenz) plus Truvada (tenofovir/emtricitabine) for almost one year. Last week, my lab tests showed that my CD4 count was 399 and my HIV viral load was less than 50 copies. (I became undetectable after the first month on meds). My question is, how much does my age factor in with regard to the rise in T-cells? Do you think they will continue to rise, or have I already reached a plateau? My T-cell count went down by 29 cells from my last test three months ago. Is this a cause for concern?

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

You are doing very well! Your CD4 count may continue to rise, but if not, you have still made good progress with your regimen. Some studies show that people with HCV co-infection appear to gain fewer CD4 cells on average after starting HIV treatment, but others do quite well. A CD4 count decrease of 29 cells is not considered significant, given your total count. There will occasionally be small decreases or increases, but these are normal fluctuations.

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

This is not a regimen that you would expect to cause side effects such as these. However, the AZT component of Combivir has been known to cause muscle aches, especially early in the course of therapy. More likely, these effects are due to some other condition. For example, at 57, you may be experiencing signs of the aging process itself.

Talk to your doctor about your symptoms. He or she may want to have you undergo some testing to determine the various possible causes of these symptoms. In the meantime, you can take Tylenol or Advil for relief of the aches and pains.

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

It is not possible to say exactly what the chances are. If there were any cuts or tears in or around his anus where blood was present, and if you had any open cuts or open sores on your penis, then there could have been transmission (assuming that he were HIV positive, which you don't know).

The best approach is to have an HIV antibody test 6 months after the incident and do not have any unprotected sex in the meantime. By that time, the test would give a definitive positive or negative result. A test prior to that time might not be accurate if you tested negative, since it can take as long as 6 months for some people to develop antibodies to HIV. If you test positive prior to the 24-week time period, that would likely be a true positive, since most people develop antibodies within a couple weeks if they have been infected.

The odds are in your favor for not being infected, even if he were positive, because generally it takes multiple exposures to HIV to become infected. From your description, it sounds like you were not at high risk for becoming infected. Still, there is some level of risk for you, even with just one encounter, and the possibility of infection cannot be ruled out altogether.