Anonymous Asked
QuestionHi thanks for your previous answers about starting meds. I have seen some guys who are hiv + on meds who are in great shape but others who say they gained weight because of the meds. Which one is it? Do meds make you gain weight? Can I still take workout supplements? Answer

You can definitely gain weight on HIV meds, but it’s not a side effect; it’s simply what we call “return to health.” When you have untreated HIV infection, especially with a high viral load, you’re likely to have trouble gaining or maintaining weight.  You could say that when you’re eating, you’re “feeding the virus,” and the ongoing, uncontrolled viral infection results in chronic inflammation, also contributing to weight loss.

When you start meds, you suppress viral replication and shut off the inflammation. You’re now feeding yourself rather than virus, and your weight returns to what it would have been if you were HIV-negative. Some people may not like that, but chronic illness is a lousy way to lose weight.

I’d have to know what you mean by workout supplements—there are so many.  Protein and creatine are generally fine.

Anonymous Asked
QuestionMy doctor told me that I tested negative but wanted to do a viral load and it came out undetectable what does this mean? Answer

It means you’re negative.  An HIV-negative person has an “undetectable” viral load, because there’s no HIV to detect.

Anonymous Asked
QuestionMy bf is 14y +, undetectable, medication adherent. I'm female, neg, on PrEP. Might we enjoy unprotected vaginal intercourse w/o fear of transmission? Answer

You scared me for a moment, because on my first reading of your question, I thought your boyfriend was 14 years old.  I’ve recovered now, having finally noticed and interpreted the “+” sign.

With his undetectable viral load and your being on PrEP, the chances of transmission are infinitesimally small—frankly, it would make medical headlines. You’ve already got both belt and suspenders holding up your pants; you don’t have to glue them to your skin.  

(I know it’s politically incorrect of me to talk about sex without condoms. When I say things like this in front of a microphone, there are invariably people in the audience who gasp and then write nasty comments on their evaluation forms.)

Of course, this presumes monogamy…something no one can ever be completely confident of, since it involves trusting your partner.  Without condoms, he could bring something else home to you.  You also have to trust that he continues to take his medications and maintains an undetectable viral load.  But at some point, relationships are about trust. If you trust your partner, you can consider condomless sex. And let’s not call it “unprotected,” because you’re already protected in two very good ways.

Anonymous Asked
QuestionJust how common are kidney and bone issues with Tenofovir? I get answers ranging from very rare, to many more issues were seen in the real world, than in trials. To reformulate it, as is being done, I would think it must be more than "extremely rare." If it is more than first thought, I do wonder why someone would choose a Tenofovir regimen, if they could just as easily go with another, like Triumeq. I mean why take any chance? Is it other regimens have their possible issues, too? Thanks! Answer

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It’s probably true that kidney issues are more common in the “real world” than in clinical trials, because real world patients are more likely to be older and to have more comorbidities (other medical conditions) than clinical trial participants, which puts them at greater risk for toxicity. In addition, while kidney problems happen both to people who take tenofovir and people who don’t,  you can bet that in the real world, if you’re on tenofovir your kidney problems will be blamed on the drug, whether it’s the cause or not. Kidney toxicity from tenofovir is “uncommon” but it’s certainly not “extremely rare,” which is the reason for the development of tenofovir alafenamide (TAF).

A small decline in bone density occurs when you initiate any new regimen that includes nucleoside analogs.  It tends to occur in the first 6 months and then levels off.  In a young, healthy person this would  be of no clinical consequence, but in an older person who already has osteopenia or osteoporosis, it could be important.  The decline in bone density is somewhat more pronounced with tenofovir than with other drugs.

So why is tenofovir preferred? The nice thing about tenofovir is that we can predict and measure toxicity fairly well.  Specifically, we can predict what will happen to bone density and we can measure what happens to kidney function, allowing us to change therapy if we see a problem.  In contrast, there’s still the question of whether abacavir (a part of Triumeq) increases the risk of heart attack. If it does, there’s no way to measure or predict the effect, other than to avoid the drug in people at the highest risk. In addition, abacavir was less effective than tenofovir in a large randomized trial. Fortunately, that doesn’t appear to be an issue when it’s used with dolutegavir (i.e. Triumeq). 

I discussed Triumeq in greater detail on this site a week or two ago.

Anonymous Asked
QuestionHi, I have 2 questions. I was diagnosed back in 2012. I am about to start taking meds and I can take any of the 1 a day regimen pills. 1. Which is the med that is likely to cause lipodistrophy? 2. I started a new job and I have read that when you start meds you get alot of side effects like diarrhea and mood swings. How long do these last and how severe are they? I'm wondering if I need to take time off Answer

1. None of the currently recommended regimens, including the singlet-tablet regimen, will cause lipodystrophy. 

2. None of the single-table regimens are likely to cause diarrhea. If it does occur, it should be very temporary.  You’re unlikely to experience mood swings with any of them except Atripla.

You should not need to take time off to adjust to treatment.  A weekend should be sufficient.

Anonymous Asked
QuestionHey Doc, I have written to you before. I was Diagnosed 11/2013. At the start my VL was less than 100 & CD4 was 1000. I have had Blood work done on 4 other occasions though out the year and overtime the numbers are relatively the same. Always between 75-100 on the VL and between 700-1000 on the CD4 count. I have looked into the non progressive and the controller theories. No meds yet My Doc is not rushing me to start them. Your thoughts? Answer

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I’m agnostic on this question.  While I  believe that almost everyone with HIV should be on treatment, I’m not sure what to do with elite controllers—people who maintain undetectable viral loads off therapy—provided their CD4 counts are high and stable. You’re almost an elite controller.

The argument in favor of treating is that elite controllers still have measurably higher levels of inflammation and immune activation than HIV-positive people whose viral loads are suppressed on antiretroviral therapy. Reducing those levels is presumably good for you over the long term.

However, I can think of two arguments against treating: First, because you’re at such low risk of developing complications in the short-term, it would be almost impossible to demonstrate that treatment has a clinically meaningful benefit, even in a very large study. Second, there’s the possibility that further suppressing your viral load would cause your immune system to “forget” about HIV, potentially taking away whatever characteristic it is that allows your immune system to keep HIV under such good control. Whether that matters, since you’d be on treatment for the rest of your life anyway, is unclear.

If you decide not to start treatment, you might want to consider joining a study.  I understand that an ACTG study is being planned to look at the effects of treating (vs. not treating) elite controllers on immune activation and inflammation.

Anonymous Asked
QuestionThanks for sending the "HIV Cascade". I've never seen this before and while I posted how shocked I was in the low percentage of undetectable individuals, I'm now more shocked to the point of disbelief as to the low number remaining in treatment. Makes me now question why the death rate isn't much higher. Answer

Yes, you should be shocked.  We should all be shocked and dismayed. Treatment is prevention, and could have a major impact on the HIV epidemic, but not if only 28% are suppressed.

Anonymous Asked
QuestionIt has been well established that hiv accelerates the aging process by 10 to 20 years, even with treatment. My question then is what about those infected later in life, say 50s and 60s when their normal life expectancy is already within that range. Can they expect a greater or some sort of ratio in this acceleration in aging theroy than say someone in their 30s-40s? Answer

In fact, it has not been well established that HIV accelerates the aging process or reduces life expectancy even with treatment.  In fact this is a subject of enormous controversy. There are a number of problems with studies that suggest this acceleration in aging. One is the use of inappropriate comparisons.  For example, many studies compare data from inner city HIV clinics—which may includes poor minorities, HCV-coinfected people, and injection drug users—with the general population. If the HIV-positive people die earlier, is it really because HIV is making them age faster, or is it because of other factors that have nothing to do with HIV?

An interesting study that does not suffer from this bias is a recent Kaiser study looking at the difference in risk of heart attack between HIV-positive an HIV-negative patients over time (see figure). They found that while historically there had been an increased risk of heart attack in HIV-positive people, that difference has been shrinking over time and has now disappeared.  The assumption is that we are using more “heart friendly” drugs to treat HIV infection and that we’re being more aggressive at treating other conditions that could increase the risk. The fact that this study comes from Kaiser means that there’s greater homogeneity than in some of the other comparison studies. In other words, the HIV-positive people are fairly similar to the HIV-negative people from a socioeconomic standpoint—they all have jobs that allow them to enroll in Kaiser for insurance. This homogeneity makes the comparison much more meaningful

There’s no question that people with well controlled HIV infection have somewhat higher levels of inflammation and immune activation than HIV-negative people, but their levels are still just a small fraction of what they would be if their viral loads weren’t suppressed.  There’s a lot of discussion and debate about how much this ongoing inflammation and immune activation will affect longevity and quality of life during the aging process, but there’s no evidence at all that it will reduce life expectancy by 10-20 years. In fact, there have been a number of studies from various countries that estimate that the life expectancy of an HIV-positive person with an undetectable viral load and a CD4 count above 500 is approximately the same as that of the general population.

Anonymous Asked
Questionhello dr , i want to ask you about condoms effectiveness , is it 100% if they stayed intact and didn't fail against HIV ? sorry for my English but I'm Arabian and its not my native language Answer

A properly used, intact condom that doesn’t break is virtually 100% effective at preventing HIV transmission.

Anonymous Asked
QuestionHow come it seems many of the older-generation of HIV infected folks (i.e. infected in 80's and 90's) have many drug resistance while those in the 2000s and today do not? Is it because they went so long without medication during those days and then took toxic medications? Or is it the fact they have had the disease 20-30 years and aging with it has developed drug resistance even to the most treatment-experienced and successfully adherent patients? Answer

See continuation below.