1MEN’S AND WOMEN’S HEALTH – NOVEMBER 15TH, 2007

HIV

LECTURE 20
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• South-east Asia is becoming the new “hub” for HIV: increasing prevelance.
• Still contracted through blood transfusions around the world.
• Prostitution: girls are told to not use condoms
• Misconceptions still around: if infected has sex with a virgin, he is cured.

Latin America
• Lots of prejudice re: gay HIV patients

Map 1:
Areas affected by HIV in 1981
Map 2: it is everywhere now.

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• About 58000 with HIV, but number is likely much higher as people aren’t aware that they have it.
• Young individuals: increasing in this population
• MSM: not all men who have sex with men are defined as “homosexual”. Increase in cases in this population.

Youth:
• 50% of cases are in youth. Many are raped.
• Number cases by MSM, heterosexual contact almost EQUAL.

Women:
• More likely to get HIV from 1 exposure, HIV has affinity for mucus membranes (vagina)

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• Stigma around having HIV, even if they were raped, or got it from their husband

Primary HIV Infection

• How do you know when someone first contracts HIV?
• May not get these symptoms for YEARS after getting exposed
• Many people will just have the night sweats, not the fever.
• Less common symptoms in the literature (slide 4): Fatigue is common.

Labs
• Viral load is very high at beginning, but will decrease over time.
• Health Canada tracks number of positive tests.

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• Highest viral load in gut (intestines). Will have diarrhea
• Lowest concentration is in the brain

• CD4 counts: these are guidelines. Not set in stone: can have low CD4 counts and not have these infections. Body is
very resilient!
• Look at the ratio between CD4, CD8, not just numbers of CD4 T-cells

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• Kaposi’s sarcoma: visible on the face. Hard for patients to deal with
• 1993: re-definition of HIV
• AIDS-indicator conditions: the opportunistic infections

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• In AIDS patients, check for TB every year

• Fungal infections: see thrush, infections of feet, big toe especially

• Cancer: co-morbidity

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• AZT was only drug used to treat AIDS in the beginning.
• Monotherapy has brief period of efficacy

• Drugs are still being developed: new drugs (1996)

• HAART=1995. Combination of drugs. Protease inhibitor and NRTI/NNRTI. But lots of side effects
• No longer a death sentence! But incredibly difficult to live with. Compared to diabetes, but patients feel that this is an
inaccurate comparision.
• Patients may object to term “cocktail”, refer to HAART, anti-retroviral therapy (ARV) instead.

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• Viral load and CD4 count is tested right before initiating therapy: want to see where they are starting from.
• “clinically indicated”: independently of their CD4 counts: some might be resistant to drugs, some might have just been
diagnosed and on ARVs.
• Important to understand conventional therapy, we will need to explain this to patients. They may not have been told
all of the details.
• If you don’t need to go on ARV therapy (CD4<500), don’t do it. Patients die from liver and other complications from
the drugs
• We don’t have therapies that will act like anti-retroviral drugs.

Drug holiday:
• Really difficult to take the meds: nausea, diarrhea, have to take a handful of drugs every day.
• Compliance with drugs essential, need 95% compliance to prevent decrease of CD4
• One patient that Dr. Khalili sees has been on 2 year drug holiday
• Can have rebound viral replication. MDs are resistant to patients doing this. More resistance when they go back on
them?

Toxicity:
• 90% of patients get peripheral neuropathy: acupuncture can help a lot
• GI side effects: don’t underestimate this. Can happen anytime, will wear diapers but may not be enough. Very
embarrassing. One Sherbourne patient committed suicide: was very frustrated with bowel incontinence.
• Many HIV patients live in poverty: can’t work
• Interns may get frustrated: patients not taking supplements, but they are already taking many drugs.

HAART complications
• Lipodystrophy: Can develop Cushings-like body shape: buffalo hump, skinny legs. Distressing for patients
• Pancreatitis: lots of pain
• HIV: short-term memory loss

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• CV disease: drugs increase triglyceride levels

Lipodystrophy:
• Losing muscle mass in arms and legs, gain in abdomen.
• Lipoatrophy: Loss of fat in face: stigma associated with this, people can “see HIV in their face”
• Normal in aging: but see this in young HIV patients. Part of process of disease, but accelerated by drugs.

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TQ: Know that NRTIs and Pis are involved in mitochondrial damage (don’t need to know specific names of drugs)

• Treatment of mitochondria: focus on CoQ10, glutathione pathway

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• Problem with fusion inhibitors: has to be injected in adipose tissue. Patients don’t have a lot, use abdomen. Sites get
red and inflamed, and sometimes run out of sites.

• Trillium: insurance that covers cost of drugs for some patients, but still have to pay annual fee

• HIV treatment
Important to ask patient how they contracted HIV
• What changes have they noticed in themselves that they think may be attributed to the virus?
• What treatment if any have been initiated, discussed, failed, etc. Are they on meds?

• Make sure that wording is sensitive when they disclose

• Important to be clear that if they are having unsafe sex, it is a criminal act. Considered to be a rape.
• Patient may not tell you they are having unprotected sex.
• Need a lot of patience, and don’t take things personally. Patient may just come to appointment and cry, may feel like
victim, may not be able to move forward.
• Encourage them to ask questions. Their other health care providers may not have told them this info.

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• Very difficult for patients maintain adequate intake: nausea
• When calculating protein intake, start with their ideal weight, not the weight that they are at now.
• Don’t crave protein, don’t have appetite for meat, chicken.
• Want low saturated fat intake. Meds increase TG, cholesterol. Hard for patients: easier to eat fast food than to make
food when they are tired.
• Some will tolerate carbs better than others. Some will have diarrhea on intake.

• Not good to have lots of raw fruits, vegetables. Cold damp in TCM = diarrhea
• If not washed properly, may get secondary infections. Soak in white vinegar for 10-20 minutes.
• Get rid of “junk” in diet.

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Diet is so much more important than supplementation!
Be on good multivitamins: especially B vitamins (at least 50mg).
Sisu has a good MV for men. Natural factors has another good one for men. Men with iron-deficiency anemia can take
MV with iron.
Vitamin A: some controversy: not good with hepatotoxicity
Vitamin C: Careful with diarrhea. Can prescribe more if they have a cold, up to bowel tolerance. Can have loose stools
at even 1000mg.

B12: great vitamin for HIV patients. 1000mcg weekly. If prescribed by MD, it is free for them.
Cal/Mag: especially for arthralgias, myalgias. Careful with 1:1 ratio: can cause diarrhea
Zinc: pulsing: if they are suffering from acute infection, give it for a short period of time. Give for 3 weeks in acute state,
then take them off.
Selenium for GSH pathway
Alpha-lipoic acid: crosses BBB
NAC: “magic” anti-oxidant for HIV. If pt. already has gastritis (many do), have to take with meals as it will make it worse.

Probiotics: if they are in an acute state, or taking ABCs, can give daily (take it away from ABCs). Can also pulse: don’t
need to keep taking them long-term
L-glutamine: does wonders for diarrhea: makes patients feel much better (good to help patient rapport!). Take away from
acid (not with orange juice)
Whey protein: especially if they are underweight and are having trouble eating: easier to consume than a meal. Can add
in other supplements, fish oil

• Exercise: want to be careful: patients may lose weight. Balance CV and resistance training. Many patients attached
to physical appearance. Some will take steroids, growth hormone to maintain body shape. Focus on the health
aspect of exercise when talking to patients about it.

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• Stress, mood management: BIG part of what is done at Sherbourne. 90% of visits are counselling! Remember that
we are not psychotherapists and they need to see one. Suicidal patients. Systiva (sp?) is an anti-depressant that
many HIV patients are on, but causes nightmares, insomnia.
• Difficult for them not “become their disease”. Spend all day trying to be healthy, taking supplements, drugs,
exercising, thinking about diet. Good to encourage them to become involved in community, volunteering, support
groups. Volunteering allows them to focus outwards. Takes their mind off diagnosis, have human contact that they
may otherwise lack.
• Do they have a good support system? Important to assess this from the beginning. They may not have told anyone
else about their diagnosis.
• If HIV is all that they are focussing on, they will be very depressed when their health isn’t good. Important for them to
realize that they still have life goals.
• Addictions are common, cocaine, crystal meth, very hard to treat. Go through cycles of treatment, then disappearing
for months.
• If you see people outside of appointment, they may not acknowledge you, have people know how they know you.
• What are the support agencies?
o PWA: People with AIDS: Toronto Bike Rally: some of money goes to Sherbourne! Looking for students to
get involved.
o ACT: Great programs for newly diagnosed, long-term survivors
o Casey House: Hospice. Nurses, MDs on site, can take care of them until they can go home again.
• Cases will be presented, but they are not testable material

Supplement cautions:
• Studies show that iron and zinc may increase viral replication: be cautious. Maybe pulsing?

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Botanical cautions:
TQ: Know St. John’s wort: it will be on exam!
Don’t prescribe to anyone on ARV meds. Alternative is 5-HTP, but not if they are on SSRIs
Can give garlic in very small doses: up to 5 when they are sick
Echinacea: better to avoid, we have many other immune enhancers

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Vitamin A: commonly deficient in HIV patients, but prescribed short-term.

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Selenium: to support GSH pathway

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• Lots of TCM used at Sherbourne. Homeopathy used too, but intake done.
• People love getting acupuncture, especially with neuropathy.
• Zheng qi is also called wei qi
• There won’t be any questions on TCM and HIV on exam.
• HIV and HCV are Toxic Heat conditions. Go internal indirectly, very quickly.

• Lots of Liver Qi stagnation (anger at diagnosis)

• You can have 2 or 3 different syndromes in combination.
• Don’t want to just treat the symptoms, long-term. Treat the constitution.

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• Lung Yin deficiency: see especially with opportunistic infections
• Spleen Qi deficiency: in vast majority of patients
• CV4 for diarrhea
• LI11: for toxic heat picture

Cases presented (not testable)

Jose: HIV patient spoke to class.

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