Features

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Nationally Known Pitt Researcher, Dr. Deborah Aaron,

dies at age 51

Are HIV Patients Aging Faster? 

GLMA Statement on MRSA Infections among Gay Men

AIDS Still an Epidemic in the U.S. 

MSM at Risk

Anal Pap Smears

Frequently Asked Questions and Answers

About Coinfection with HIV and Hepatitis C Virus

Living with Lipodystrophy

Pitt Researcher, Dr. Deborah Aaron, dies at age 51

Dr. Deborah Aaron, a long-time advocate and researcher in the area of LGBT health, died at her Churchill home on April 23, 2008, after a long battle with cancer.   

Dr. Aaron gained notoriety among her peers for her groundbreaking research involving the health of the lesbian community.  She was an associate professor of health and physical activity at the University of Pittsburgh, School of Education. 

Dr. Anthony Silvestre, Associate Professor in the Graduate School of Public Health, and friend of Dr. Aaron, explained that although her death was a great loss to the community, her groundbreaking research will leave an unforgettable legacy.  “Dr. Aaron made LGBT history when she and her colleagues got the National Institutes of Health to fund the first ever study of cardiovascular disease among lesbians,” he explained. “Her courage, keen intellect, and deep caring will continue to have a major role in improving the health of countless LGBT people.

Her obituary in the local Post Gazette can be found here.

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Are HIV Patients Aging Faster?

People with HIV and AIDS are living longer than ever before, thanks to the use of highly active antiretroviral therapy developed in the mid 1990’s.  As a result, men and women who become infected today have reason to be more hopeful than their counterparts from the mid to late 1980’s.  But, as a recent New York Times story points out, living longer can come at a price.  In the article AIDS Patients Face Downside of Living Longer, reporter Jane Gross interviews a handful of middle-aged men and women infected with HIV and draws connections between HIV and other conditions normally associated with advanced age. “That is the question, heretical to some,” she writes, “that is now being voiced by scientists, doctors and patients encountering a constellation of ailments showing up prematurely or in disproportionate numbers among the first wave of AIDS survivors to reach late middle age.”  Gross goes on to mention the MACS (the Multi-Site AIDS Cohort Study) and the burgeoning research being conducted by Dr. John Phair, an Infectious Disease Specialist from Chicago, Illinois.  Phair sums up the dilemma when he notes: “Which health issues are a direct result of aging, which are a direct result of HIV and what role do HIV meds play?”  In short, we don’t know. There isn’t enough research as of yet to make any definite conclusions.

Marcy Holloway, a physician assistant at the Pitt Men’s Study (which is part of the MACS), sees the problem on a day-to-day basis. “We also have experienced the concern of the rising possibility of the accelerated aging process in our older H.I.V. infected population,” she said.  “Over the past year, our study participants have undergone several tests designed to measure frailty.  Although there isn’t one easily defined mechanism to diagnose a person as being frail, studies show that there are certain characteristics that may be present in describing that person as being in the late stage of the aging process.”  When asked specifically how the Study measures ageing in middle-aged H.I.V. infected participants, she went on to say: “Literature describes frailty based on self reported or easily measured methods which include at least three out of five specific components--physical shrinking, weakness, exhaustion, slowness, and a low physical activity level.  All of these components are measured to some extent among our study participants.” 

Bill Buchanan, who has been with the Pitt Men's Study for almost 20 years, was quick to add: "A lot of people, including some government officials, think that we have HIV/AIDS licked, but we don't.  It's true that we have more effective treatments, but we still don't have a cure or a vaccine, and we still don't understand the long term effects of the drugs and of living with the virus for decades. When people think they don't have to worry about HIV/AIDS any more, that they can just take some pills and they'll be fine, they send the wrong message, especially to young people.  If you think it's okay to have sex without a condom, ask those of us who remember burying our friends…or ask the men with HIV who take handfuls of pills every day and have serious side effects - they'll tell you you're dead wrong."

Ms. Holloway couldn’t have agreed more. “The painful truth is that we’re now seeing a rise in infection rates, especially in the younger MSM population as well as people of color, with one of the primary reasons being that many believe we can completely manage HIV and AIDS with a simple anti-viral medication regimen. We just don’t know how manageable it really is.  And the older the infected populations become, the more we’re beginning to see the long-term negative effects of both the disease and the anti-viral treatments.  So we have to keep up the momentum in funding, research, and prevention.”

You can find the New York Times article by clicking here.

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GLMA Statement on MRSA

A recent study published in the Annals of Internal Medicine showed a drug resistant strain of MRSA (Methicllin-resistant Staphylococcus aureus) being spread among gay men in San Francisco and Boston.  The resulting media coverage, such as the January 15th article in the New York Times, New Bacteria Strain Is Striking Gay Men, caused some concern in the LGBT community.  So much so, that the follow press release was issued from the Gay and Lesbian Medical Association. 

SAN FRANCISCO--January 18, 2008-- There has been widespread media coverage recently about a drug-resistant strain of MRSA bacteria, known as USA300, found in gay men in San Francisco and Boston. The findings were reported in the Annals of Internal Medicine.

Unfortunately, some of the media stories have made claims not fully supported by the research or have stigmatized gay men by distinguishing them from “the general population.” Further, some right wing groups and commentators have seized upon this story as an opportunity to spread misinformation about homosexuality.

Epidemiological research documenting the spread of this strain was posted in an online article on the Annals of Internal Medicine website. The strains of MRSA described in the article have mostly been identified in certain gay men in only two geographic regions and specific sexual behaviors were not assessed, so no conclusions can be drawn about the prevalence of these strains among all gay men or about the association of the infection with specific male-male sexual practices.

While the infection may be linked to intimate contact, the infection can also be spread by skin-to-skin contact and by sharing towels and other personal items. The CDC states that there “is no evidence at this time to suggest that MRSA is a sexually-transmitted infection in the classical sense.”

MRSA infection can be a serious matter, but if recognized early, the infection can be treated effectively. The CDC recommends the following to prevent the spread of MRSA:

1. Cover your wound. Keep wounds that are draining or have pus covered with clean, dry bandages. Follow your healthcare provider’s instructions on proper care of the wound. Pus from infected wounds can contain staph and MRSA, so keeping wounds covered will help prevent the spread to others. Bandages or tape can be discarded with the regular trash.

2. Clean your hands. You, your family, and others in close contact should wash their hands frequently with soap and warm water or use an alcohol-based hand sanitizer, especially after changing the bandage or touching the infected wounds.

3. Do not share personal items. Avoid sharing personal items such as towels, washcloths, razors, clothing, or uniforms that may have had contact with infected wounds or bandages. Wash sheets, towels, and clothes that become soiled with water and laundry detergent. Drying clothes in a hot dryer, rather than air-drying, also helps kill bacteria in clothes.

4. Talk to your doctor. Tell any healthcare providers who treat you that you have or had a staph or MRSA skin infection.

Information from The Gay and Lesbian Medical Association

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AIDS Still an Epidemic in the U.S. 

Recent articles in the Washington Post and the New York Times exemplify how serious the AIDS epidemic continues to be. 

On December 3rd, 2007, the Post reported that new government estimates of Americans who become infected with HIV is significantly higher than previous calculations.

“For more than a decade, epidemiologists at the Centers for Disease Control
and Prevention have pegged the number of new HIV infections each year at
40,000,” the article explained. But officials at the CDC have confirmed more recently that the number is actually somewhere between 55,000 and 60,000. Reasons for the dramatic increase are uncertain and investigators say it could take years of research before they have an answer.    

In a related story, the Times recently revealed that the District of Columbia

has the highest rate of AIDS infection of any city in the country and “the disease is being transmitted to infants, older adults, women and heterosexual men at an epidemic pace….”

In an official report, DC health officials warned “HIV/AIDS in the district has become a modern epidemic with complexities and challenges that continue to threaten the lives and well-being of far too many residents….”  The report stated that more than 12,400 people in the city (about 1 in 50) are living with HIV or AIDS and explained that “unprotected sex was the most common way HIV is spread, followed by intravenous drug use.”

Since 2000, about 13 percent of all new H.I.V. cases in DC involved intravenous drug use.  Not surprisingly, Washington is still the only city in the country barred by federal law from using local tax money to finance needle exchange programs.

When asked about the recent news, Dr. Anthony Silvestre, a co-investigator for the Pitt Men's Study, was quick to note “The recent reports are quite disturbing. The data show that not enough is being done to stop the spread of HIV in this country.”  When asked specifically about the situation in DC, he went on to say: “We see once again that government is lax in its attention to this disease and its commitment to the health of minority people.” 

For the full story in the Washington Post, go to: http://www.washingtonpost.com/wp-dyn/content/article/2007/11/30/AR2007113002535_pf.html

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MSM at Risk

Throughout the course of any disease (especially where no cure exists) rates of infection rise and fall over the course of time.  Recent data from many corners of the world tell us that HIV infection is on the rise.  What factors are at work in the rising rates of infection in MSM in developed and developing countries?  A recent publication by amfAR (American Foundation for AIDS Research) the recent rise can be attributed to a complex set of biological, behavioral, and socio-cultural factors that may place MSM at increased risk for acquiring and transmitting HIV.

Biological Factors

There are biological factors associated with male-to-male sexual behavior—in particular, anal intercourse—that do increase individuals’ risk.

• Rectal tissue is much more vulnerable to tearing (than vaginal) during intercourse and the larger surface area of the rectum/ colon provides more opportunity for viral penetration and infection.  Both vaginal and anal intercourse have been shown to be efficient routes for HIV transmission, as the epithelium of both tracts has receptors that easily bind to HIV.
• The presence of genital ulcer disease (GUD), most notably herpes simplex virus-2 (HSV-2), primary syphilis, and chancroid, also facilitates HIV acquisition. Many MSMs and the providers to whom they go for care do not think to screen for STIs that present rectally, resulting in infections that go undiagnosed and untreated.

Behavioral Factors

Several behavioral risk factors can also increase the vulnerability of MSM to HIV infection.

• Specific sexual acts increase the risk of HIV infection in MSMs. In descending order of risk, these include unprotected receptive anal intercourse, unprotected insertive anal intercourse, and oral sex.
• Other practices including multiple sex partners, inconsistent condom use, lack of knowledge about HIV risk, and negative or complacent attitudes toward safer sex have also been shown to be factors associated with increased risk of HIV infection.
• The utilization of alcohol and drug use in the MSM population is also quite high, which in turn can increase the risk for acquiring HIV.  Several studies link alcohol and drug use (particularly methamphetamine) to higher rates of unprotected anal intercourse, higher numbers of sex partners and inconsistent condom use.
• Depression in MSM has been linked to increases in risky behaviors such as unprotected anal intercourse, drug and alcohol use, inconsistent condom use, and multiple sexual partnerships.
• Some studies have found that MSM, particularly young MSM, who have a history of childhood sexual abuse are more likely to engage in high-risk behaviors, such as unprotected anal intercourse, substance abuse, and exchanging sex for money or drugs. These studies also found that MSM with a history of childhood sexual abuse are more likely to report being HIV positive and to have experienced relationship violence.
• The Internet offers a wider pool of men available for sexual liaisons, often on short notice. These expeditious partnerships may also bring increased risk of HIV infection.

Socio-Cultural Factors

Socio-cultural factors, such as perceptions and experiences of stigma and discrimination, homophobia, racism, and internalized oppression, may also lead to increased risk of HIV infection in MSM.

• Several studies indicate that these factors may play a significant role in increasing the risk of drug use before or during sexual encounters, unprotected insertive/receptive anal sex, multiple sexual partnerships, and inconsistent condom use.
• Stigma associated with acknowledging homosexual or bisexual activity may inhibit many MSM from identifying as such, potentially leading to denial of their own risk and alienation from prevention programs that target self-identified gay/bisexual populations.
• Social and economic factors, such as higher rates of poverty, unemployment, and lack of health care access, that are often more prevalent in communities of color may be associated with risk behaviors that facilitate HIV infection and with reduced access to testing, prevention, and treatment services.
• Optimism about the availability and efficacy of new HIV therapies has been associated with sexual risk behavior in young MSM.

Since the beginning of the HIV/AIDS epidemic, individual-level, small group, and community level behavioral prevention interventions targeting at-risk MSM have been effective in changing risk behaviors that facilitate HIV transmission and acquisition.

• A recent review of behavioral interventions in MSM population found that these interventions reduced the number of unprotected sex acts, reduced the number of sex partners, reduced unprotected anal intercourse by 23%, and increasing condom use by 61%.
• Successful interventions incorporated interpersonal skills-building, utilized several delivery methods, and were delivered over multiple sessions.
• In communities where these interventions have been implemented, rates of unprotected anal sex decreased, condom use increased, and overall numbers of sex partners decreased.
• In addition to behavioral interventions, a few promising biomedical approaches are being tested for prevention of sexual transmission of HIV in MSM. Two such approaches are the treatment of HSV-2 infection among HIV-negative MSM to reduce risk of HIV acquisition, and the use of pre-exposure prophylaxis (PrEP).  Additionally, there are continued efforts to develop safe and effective topical microbicides (that could be used rectally)  and vaccines that may be helpful in preventing HIV infection in this population.

Despite the success of these interventions, there are many barriers to reaching all members of the MSM population.  For example, government supported programs that promote abstinence-only-until-marriage as an HIV prevention strategy implicitly and explicitly condemn or deny the existence and sexual rights of gay, bisexual, and transgendered people.   Moreover, educational curricula supported through these programs in many cases convey medically inaccurate information about STIs and HIV infection. They are prohibited by law from providing information about the significant effectiveness of male condoms for HIV prevention, and instead must emphasize their failure rates.  This may have the deleterious effect of discouraging condom use, which in turn could increase the risk of HIV infection in MSM.

Given the demonstrated success of many of these intervention programs in reducing risky behaviors, it appears that there is ample justification for increased funding for these programs.  However, these programs do not operate in a vacuum.  In addition to increased funding, these programs need a more favorable environment, free biases and prejudices that should play no role in addressing this epidemic.  More research should be conducted to validate specific methods and improve the direction of others.  Despite the enormous progress that has been made in the development and implementation of intervention strategies, much work remains. 

Information from www.amfar.com

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Anal Pap Smears

The anal PAP is a test that can identify changes in cells in and around the anus and rectum. These changes are precursors to anal cancer, a type of cancer on the rise in gay and bisexual men.

Anal cancer in men and cervical cancer in women are both thought to be linked to the Human Papilloma Virus or HPV.  HPV, the same virus that causes genital warts is common, especially in bisexual and gay men.  It is believed that the prevalence of HPV in gay and bisexual men has caused the rise in anal cancers. Studies vary but it is estimated that for men who have sex with men, 35 of every 100,000 will develop anal cancer.  HIV infected people are twice as likely to contract anal cancers as are HIV negative people.  Gay and bisexual men with HIV are especially at risk because they are at higher risk for persistent HPV infection. 

The biggest risk factors for anal HPV are multiple sexual partners and anal sex. But even if someone has never had anal sex, every man who has sex with men is at risk for it. Genital HPV can spread from skin-to-skin contact. It doesn't require penetration. A finger can spread it, or someone might rub his penis on the outside of his partner's anus during foreplay, and from there it's easy for the virus to spread inside. And a condom may not be protective. It doesn't cover the base of the penile shaft, the pubic hair or the scrotum, which are all places where HPV can be found.

The anal PAP screening is very simple, painless, and quick. A qualified health care professional will collect cell samples from the anal canal by swabbing all surfaces of the anus and rectum. These cell samples are sent to a lab where technicians prep the samples and look at them under a microscope. In a few days, the physician will have the results and will discuss them with you.  If there's an abnormal Pap smear, then we do a procedure called a high-resolution anoscopy, which is actually looking inside the rectum to see what abnormalities are there.  There are different grades of cellular abnormality, from atypical cells of unknown significance, to low grade and high grade dysplasia.  Changes indicative of high grade dysplasia are generally biopsied by a pathologist for further diagnosis.

Some Public Health experts found that screening gay and bisexual men every three years would identify many cases of anal cancer early -- when they can be treated successfully.  Initially, the cells in the anal canal develop abnormal, pre-malignant changes called intraepithelial (the superficial layer of the anal canal) neoplasms. With early detection these cellular abnormalities can be treated.  If untreated these changes gradually worsen and can become an invasive cancer.  Others are less certain.  Some believe that though circumstantial evidence indicates that the anal dysplasia that is found on the anal pap is a precursor to cancer, there is no model of the natural history of these lesions to cancer.  They further believe that more research is needed to improve our understanding of the link between HPV and anal cancer.  Less than 10 percent of high-grade dysplasia goes on to cancer, but we don't know which 10 percent.

Regular anal PAP screenings can be an important part of staying healthy while living with HIV. For more information, ask your doctor or health care professional.

Information from:    About Health and Fitness

                                  Salon.com

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Frequently Asked Questions and Answers

About Coinfection

with HIV and Hepatitis C Virus

Why should HIV-infected persons be concerned about coinfection with HCV?

About one quarter of HIV-infected persons in the United States are also infected with hepatitis C virus (HCV). HCV is one of the most important causes of chronic liver disease in the United States and HCV infection progresses more rapidly to liver damage in HIV-infected persons. HCV infection may also impact the course and management of HIV infection.

The latest U.S. Public Health Service/Infectious Diseases Society of America (USPHS/IDSA) guidelines recommend that all HIV-infected persons should be screened for HCV infection. Prevention of HCV infection for those not already infected and reducing chronic liver disease in those who are infected are important concerns for HIV-infected individuals and their health care providers.

Who is likely to have HIV-HCV coinfection?

The hepatitis C virus (HCV) is transmitted primarily by large or repeated direct percutaneous (i.e., passage through the skin by puncture) exposures to contaminated blood. Therefore, coinfection with HIV and HCV is common (50%-90%) among HIV-infected injection drug users (IDUs). Coinfection is also common among persons with hemophilia who received clotting factor concentrates before concentrates were effectively treated to inactivate both viruses (i.e., products made before 1987). The risk for acquiring infection through perinatal or sexual exposures is much lower for HCV than for HIV. For persons infected with HIV through sexual exposure (e.g., male-to-male sexual activity), coinfection with HCV is no more common than among similarly aged adults in the general population (3%-5%).

What are the effects of coinfection on disease progression of HCV and HIV?

Chronic HCV infection develops in 75%-85% of infected persons and leads to chronic liver disease in 70% of these chronically infected persons. HIV-HCV coinfection has been associated with higher titers of HCV, more rapid progression to HCV-related liver disease, and an increased risk for HCV-related cirrhosis (scarring) of the liver. Because of this, HCV infection has been viewed as an opportunistic infection in HIV-infected persons and was included in the 1999 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus. It is not, however, considered an AIDS-defining illness. As highly active antiretroviral therapy (HAART) and prophylaxis of opportunistic infections increase the life span of persons living with HIV, HCV-related liver disease has become a major cause of hospital admissions and deaths among HIV-infected persons.

The effects of HCV coinfection on HIV disease progression are less certain. Some studies have suggested that infection with certain HCV genotypes is associated with more rapid progression to AIDS or death. However, the subject remains controversial. Since coinfected patients are living longer on HAART, more data are needed to determine if HCV infection influences the long-term natural history of HIV infection.

How can coinfection with HCV be prevented?

Persons living with HIV who are not already coinfected with HCV can adopt measures to prevent acquiring HCV. Such measures will also reduce the chance of transmitting their HIV infection to others.

Not injecting or stopping injection drug use would eliminate the chief route of HCV transmission; substance-abuse treatment and relapse-prevention programs should be recommended. If patients continue to inject, they should be counseled about safer injection practices; that is, to use new, sterile syringes every time they inject drugs and never reuse or share syringes, needles, water, or drug preparation equipment.

Toothbrushes, razors, and other personal care items that might be contaminated with blood should not be shared. Although there are no data from the United States indicating that tattooing and body piercing place persons at increased risk for HCV infection, these procedures may be a source for infection with any blood borne pathogen if proper infection control practices are not followed.

Although consistent data are lacking regarding the extent to which sexual activity contributes to HCV transmission, persons having multiple sex partners are at risk for other sexually transmitted diseases (STDs) as well as for transmitting HIV to others. They should be counseled accordingly.

How should patients coinfected with HIV and HCV be managed?

General guidelines

Patients coinfected with HIV and HCV should be encouraged to adopt safe behaviors (as described in the previous section) to prevent transmission of HIV and HCV to others.

Individuals with evidence of HCV infection should be given information about prevention of liver damage, undergo evaluation for chronic liver disease and, if indicated, be considered for treatment. Persons coinfected with HIV and HCV should be advised not to drink excessive amounts of alcohol. Avoiding alcohol altogether might be wise because the effects of even moderate or low amounts of alcohol (e.g., 12 oz. of beer, 5 oz. of wine or 1.5 oz. hard liquor per day) on disease progression are unknown. When appropriate, referral should be made to alcohol treatment and relapse-prevention programs. Because of possible effects on the liver, HCV- infected patients should consult with their health care professional before taking any new medicines, including over-the-counter, alternative or herbal medicines.

Susceptible coinfected patients should receive hepatitis A vaccine because the risk for fulminant hepatitis associated with hepatitis A is increased in persons with chronic liver disease. Susceptible patients should receive hepatitis B vaccine because most HIV-infected persons are at risk for HBV infection. The vaccines appear safe for these patients and more than two-thirds of those vaccinated develop antibody responses. Prevaccination screening for antibodies against hepatitis A and hepatitis B in this high-prevalence population is generally cost-effective. Postvaccination testing for hepatitis A is not recommended, but testing for antibody to hepatitis B surface antigen (anti-HBs) should be performed 1-2 months after completion of the primary series of hepatitis B vaccine. Persons who fail to respond should be revaccinated with up to three additional doses.

HAART has no significant effect on HCV. However, coinfected persons may be at increased risk for HAART-associated liver toxicity and should be closely monitored during antiretroviral therapy. Data suggest that the majority of these persons do not appear to develop significant and/or symptomatic hepatitis after initiation of antiretroviral therapy.

Treatment for HCV Infection

A Consensus Development Conference Panel convened by The National Institutes of Health in 1997 recommended antiviral therapy for patients with chronic hepatitis C who are at the greatest risk for progression to cirrhosis. These persons include anti-HCV positive patients with persistently elevated liver enzymes, detectable HCV RNA, and a liver biopsy that indicates either portal or bridging fibrosis or at least moderate degrees of inflammation and necrosis. Patients with less severe histological disease should be managed on an individual basis.

In the United States, two different regimens have been approved as therapy for chronic hepatitis C: monotherapy with alpha interferon and combination therapy with alpha interferon and ribavirin. Among HIV-negative persons with chronic hepatitis C, combination therapy consistently yields higher rates (30%-40%) of sustained response than monotherapy (10%-20%). Combination therapy is more effective against viral genotypes 2 and 3, and requires a shorter course of treatment; however, viral genotype 1 is the most common among U.S. patients. Combination therapy is associated with more side effects than monotherapy, but, in most situations, it is preferable. At present, interferon monotherapy is reserved for patients who have contraindications to the use of ribavirin.

Studies thus far, although not extensive, have indicated that response rates in HIV-infected patients to alpha interferon monotherapy for HCV were lower than in non-HIV-infected patients, but the differences were not statistically significant. Monotherapy appears to be reasonably well tolerated in coinfected patients. There are no published articles on the long-term effect of combination therapy in coinfected patients, but studies currently underway suggest it is superior to monotherapy. However, the side effects of combination therapy are greater in coinfected patients. Thus, combination therapy should be used with caution until more data are available.

The decision to treat people coinfected with HIV and HCV must also take into consideration their concurrent medications and medical conditions. If CD4 counts are normal or minimally abnormal (> 400/ul), there is little difference in treatment success rates between those who are coinfected and those who are infected with HCV alone.

Other Treatment Considerations

Persons with chronic hepatitis C who continue to abuse alcohol are at risk for ongoing liver injury, and antiviral therapy may be ineffective. Therefore, strict abstinence from alcohol is recommended during antiviral therapy, and interferon should be given with caution to a patient who has only recently stopped alcohol abuse. Typically, a 6-month abstinence is recommended for alcohol abusers before starting therapy; such patients should be treated with the support and collaboration of alcohol abuse treatment programs.

Although there is limited experience with antiviral treatment for chronic hepatitis C of persons who are recovering from long-term injection drug use, there are concerns that interferon therapy could be associated with relapse into drug use, both because of its side effects and because it is administered by injection. There is even less experience with treatment of persons who are active injection drug users, and an additional concern for this group is the risk for reinfection with HCV. Although a 6-month abstinence before starting therapy also has been recommended for injection drug users, additional research is needed on the benefits and drawbacks of treating these patients. Regardless, when patients with past or continuing problems of substance abuse are being considered for treatment, such patients should be treated only in collaboration with substance abuse specialists or counselors. Patients can be successfully treated while on methadone maintenance treatment of addiction.

Because many coinfected patients have conditions or factors (such as major depression or active illicit drug or alcohol use) that may prevent or complicate antiviral therapy, treatment for chronic hepatitis C in HIV-infected patients should be coordinated by health care providers with experience in treating coinfected patients or in clinical trials. It is not known if maintenance therapy is needed after successful therapy, but patients should be counseled to avoid injection drug use and other behaviors that could lead to reinfection with HCV and should continue to abstain from alcohol.

For more information on this and other health topics visit cdc.gov

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Living with Lipodystrophy

Seven years ago the Pitt Men's Study began collecting additional blood samples from participants as part of a MACS-wide lipodystrophy study.  Since then lipodystrophy has moved from an obscure metabolic phenomenon to a well-know and widely researched disease.  Today national and international research abounds to develop a better understanding of this condition.  Yet despite all this attention much of the lipodystrophy story is still a mystery.  For all we have learned definitive answers for causes, cures, and even treatments have eluded us.

What is Lipodystrophy

Lipodystrophy, or "lipo" for short, is a collection of body shape changes in HIV+ individuals, some of whom are taking anti-HIV medications (and some of whom are not). "Lipo" refers to fat, and "dystrophy" means bad growth. These changes, sometimes seemingly contradictory, include:

• Sunken cheeks in the face
• Increase of fat in the face
• Prominent veins in the legs (not associated with heavy exercise or muscle building routines)
• Loss of fat in the legs and arms
• Loss of shape in the buttocks
• Increase in fat around the gut (called truncal or central obesity. This is not the soft fat deposit under the skin that is associated with ageing, but a rapid increase in girth caused by the accumulation of hard fat deposits behind the abdominal muscles)
• Breast enlargement
• Fat pad on back of neck (sometimes called buffalo hump)
• Lipomas (fatty growths in different parts of the body)

Metabolic changes can include increases in blood fats or lactic acid, and some people even become "insulin resistance".  These metabolic changes can be seen in laboratory abnormalities that sometimes include:

• Increases in triglyceride levels
• Changes in cholesterol levels (increases in LDL, or bad cholesterol, decreases in HDL, or good cholesterol)
• Start of diabetes or insulin resistance
• Elevated blood pressure

Although some aspects of this phenomenon were seen in earlier years of the epidemic, reports have increased since 1996 with the widespread use of three-drug anti-HIV therapy.

Despite the general agreement on accepted features of the condition, there is no clear, precise definition of lipo that would provide a common objective measure.  To complicate matters further, not all researchers and clinicians accept the same definitions of symptoms, and some require multiple and or lab abnormalities.  As a result, clinicians report that between 5% and 75% of patients have signs of lipo, while many researchers think the truer rate is about 50%.

Although it is not life threatening, lipodystrophy is a serious health problem. High blood fats can increase the risk of heart disease, and lactic acidosis, although rare, can be fatal.  Body shape changes can be very upsetting causing some patients even stop taking their medications.  Insulin resistance can lead to diabetes and weight gain, and can increase the risk of heart disease.  Fat deposits behind the neck (buffalo humps) can get big enough to cause headaches and problems with breathing and sleeping, while enlarged breasts in women can be painful.

What Causes Lipodystrophy

It is also not clear what causes lipo. In fact some researchers believe that there may be different causes for the various symptoms.  One theory is that some treatment medications may interfere with the body's processing of fat. Protease inhibitor molecules for example are similar to some human proteins that process and transport fat. However, some patients who have never taken protease inhibitors have lipo.  Another theory is that insulin resistance plays a role in lipo. People with insulin resistance tend to gain weight in the abdomen.  However, the linkage between HIV infection or treatments and insulin resistance is not clear.

Some speculate that it may be caused by rapid and sustained decreases in viral load (HIV RNA levels). This may not be unique to a particular class of anti-HIV drugs but related only to the potency of the total regimen, with the most potent regimens posing the greatest risk. It may also be caused by HIV itself interfering with how the body processes fats.  Some manifestations of lipodystrophy, like wasting in the face, arms, and legs, have been common since the earliest days of the epidemic. Or, it may even be due to the immune system becoming more aggressive once the onslaught of HIV is slowed down in response to therapy. Finally, it may be due to a combination, or different combinations, of these factors.

Lipo may also be similar to "Syndrome X" which may be characterized as a recovery reaction.  Syndrome X can occur in people who have recovered from serious illnesses like childhood leukemia or breast cancer. For people with HIV, this may be caused by the recovery of the immune system after effective ART. In fact, lipo is more common in people who are doing well on their ART.

However, problems exist with all of these theories as a consistent unifying cause primarily because of the frequency of contradictory symptoms. Though the cause of lipo is uncertain, a large study found that the following factors appear to increase the risk of developing lipodystrophy:

• Age over 40 years
• Having AIDS for over 3 years
• Lowest CD4 count was below 100
• White race

Yet despite the risk associated with these factors only some people with HIV on anti-HIV therapy develop lipodystrophy.

Can Lipodystrophy beTreated?

Because we don't know what causes lipo, we don't know how to treat it. Body changes sometimes get worse, stop or get better by themselves. However, it takes a long time to reverse changes in body shape.  Some people stop taking protease inhibitors to try to reverse lipo. Some changes in ART lead to improvements in certain signs.  Changing or stopping antiviral ART is not recommended

There are a few reports of good results from people who increased their exercise, or who changed their diets. Human growth hormone or testosterone might help some lipo symptoms. Some doctors use medications to lower cholesterol and triglycerides, or to improve insulin sensitivity. More attention is being paid to assessing and reducing the risk of heart disease in patients with HIV. Until more is known about specific causes and treatments for lipo as it relates to HIV infection and treatment, its symptoms are treated the same way as for the general population.

Information from:            The Body.com

                                   AIDSInfo

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