I am a practicing registered dietitian in an outpatient clinic dealing with HIV and AIDS patients. I appreciate you tackling a subject with a paucity of research, particularly from the diet and lifestyle perspective [HIV Treatment Series, “Early Intervention for Metabolic Complications of HIV,” March/April 2006]. However, I must say that I was taken aback by many of your proposed food recommendations. Why all the organic food choices? Most of the patients who I see can hardly afford regular foods. It seems that you may have allowed your personal preferences to govern your recommendations rather than keeping at heart the socioeconomic status of many of the people infected with HIV. Secondly, to my knowledge, there have been no clear-cut studies demonstrating that “organic foods” are any better nutritionally than their conventionally grown counterparts. Although I do agree that there are definitely better choices when it comes to carbohydrates, using the glycemic index to classify foods as “good” or “bad” is highly controversial. In a patient population that often falls short on meeting their nutritional needs, all foods, even in the context of metabolic complications of HIV, have a place in a well-balanced meal plan.

Jeffrey Luckring, MS, RD

Carla Heiser responds: Borrowing from the well-designed endocrine and cardiology literature, data regarding insulin resistance and metabolic syndrome dates back to the 1970’s. Certainly diet and lifestyle information that gets translated to consumers is confusing—with mixed messages and new spins for the “in-style” diet du jour. I will counter the reference to a paucity of research though. For example, a quick search of “glycemic index” at www.pubmed.com reveals 831 articles, 112 of which are randomized, controlled studies in humans.

As for organic and hormone-free food, we need to be responsible in our counseling of clients with a variety of income levels. Organic food selection becomes a personal choice, based on preferences for taste, quality, and cost effectiveness. We recommend shifting from fast food and junk food to eating a balanced diet consisting of “real, whole food.” We encourage avoiding processed, canned, and pre-prepared foods, as well. Depending on individual factors, however, a serving of canned fruit and nuts is more nutritious than “Pop-Tarts and soda or juice.”

When there are clinical issues with hormone imbalance in particular, impacting a majority of our HIV-positive patients, selecting hormone-free foods can be a sensible and practical first-line approach. When possible, we prioritize hormone-free dairy, eggs, meat, and poultry. Outlets like Trader Joe’s (owned by Aldi’s) are promoting more affordable health food selections. The other good news is that mainstream supermarkets and price competitive venues like Walmart will be introducing organic foods, if they are not already available. It becomes our job to help with consistent messages that impact health outcomes effectively. Organic sugar is still sugar.

References:

At the moment, I continue to serve as the inmate program coordinator of Marcy Correctional Facility; our program here is for AIDS counseling and education. We always rely on outside help with information to educate ourselves. Without this assistance we are unable to educate the inmate population.

I have been HIV-positive now for 18 years, and hepatitis C-infected for well over 20 years. I am currently on the hepatitis C treatment, and in three months of treatment I was able to bring my hepatitis C viral load from one million down to undetectable levels, which is a blessing for a person with cirrhosis. I will soon write about my experience while on treatment; both my doctor and I were amazed with the results.

Most people with genotype 2B do well, but with cirrhosis it does become difficult to reach the goal of undetectable levels. I have been on the treatment since December 2005 and it was a challenge here in New York State Corrections to receive the treatment because of the policy in place. However, Corrections was forced to change the policies in order to benefit us all. Corrections is always interested in saving a penny rather than saving lives. They did not want to treat those with hepatitis C without their participation in a substance abuse program and wouldn’t treat those with less than 15 months before release. Also, the substance abuse program in New York City’s DOC [Department of Corrections] gets you into the program within two years of your earliest release, so the new changes did make a big difference in many people’s lives. The new policy changes consist of your encouragement to participate in a substance abuse program, and it does not matter the amount of time left on your release date. Furthermore, it will be linked to a hospital or clinic upon release.

William Lopez, 0414146, Coordinator, P.A.C.E., Marcy Correctional Facility, Box 3600, Marcy, N.Y. 13403–3600

I have a tricky treatment question: Do I have any options other than my current regimen besides Fuzeon? My history: saquinavir [Invirase], AZT [Retrovir], and 3TC [Epivir] in 1996. I dropped saquinavir and added Crixivan in ’97. My doctor suggested dropping AZT in ’99 due to fatigue, so I used Crixivan, d4T [Zerit] and 3TC until 2001 (undetectable viral load and high T-cells—600–800). Facial and limb atrophy prompted me to switch to Trizivir in 2002. Trizivir was stopped due to fatigue in mid-2002. A genotype test in ’02 indicated “susceptible” to all [protease inhibitors] and NNRTIs [non-nucleoside reverse transcriptase inhibitors]; high level resistance to 3TC, abacavir [Ziagen, one of the drugs in Trizivir], and AZT; intermediate level resistance to d4T, ddC [Hivid], and ddI [Videx] (K70R, M184V, M41L, T215Y/F mutations). Viracept, d4T, and ddI were tried and dropped due to stomach problems in ’02. No HIV meds from August ’02 to September ’03. My T-cells fell to 309 (22%) and viral load climbed to 250,000 in that time. I started Viramune, ddI, Viread, and 3TC (later Truvada), which brought my viral load down to undetectable, but T-cells declined to low 200s (lowest ever; %’s around 20) in ’04. In ’04 and ’05 I got stabbed 12 times (ultimately, more a mental than physical impact), experienced wasting syndrome, balance problems, peripheral neuropathy in my feet, depression, and anxiety. In March ’05, I dropped ddI and Viread and started Kaletra, Viramune, and 3TC (then dropped 3TC). In ’06, my neuropathy is slowly improving, and I have gained my weight back. However, Kaletra caused much diarrhea, bloating, and gas. Two weeks ago, I switched to Lexiva, Norvir, and Viramune to see if that makes any difference. No difference. I know that “protocol” indicates that PI-experienced folks do not use Lexiva without Norvir, but what do you think my chances would be on Lexiva and Viramune? What about Lexiva and Viramune, and Norvir at night (100 mg), but not in the a.m. (the daytime dose seems to be the primary culprit)? Crixivan and Viramune? Are there any other alternatives besides Fuzeon? Should I get another genotype test? My doctor is great, but not very sympathetic to the mentally and socially debilitating effects of chronic GI [gastrointestinal] problems. I am trying to dig myself out of depression and anxiety, and the stomach problems only add to them. I am also on acyclovir, Klonapin, Pilocarpine, Avapro, Vicodin (for chronic pain from a botched anal wart laser surgery), Fentanyl (for neuropathy), and Lexapro. I smoke pot semi-regularly, but not in great quantities. I drink two or three drinks every night, which I am working to reduce. Any insight would be greatly appreciated.

Name withheld, via the Internet

Dr. Dan Berger responds: I will comment on some particulars of your history. We now know that ddI plus Viread when combined in a non-nuke regimen (in your case, Viramune) is associated with T-cell deterioration and should not be used. Also, there is a new protease inhibitor called darunavir (TMC-114) [see “New HIV drug: Prezista,” p. 13]. It is effective against most protease inhibitor mutations and will likely be very effective for you. Finally, I would like to see a phenotype with the genotype (not a virtual phenotype) so that we can get a clear picture of what can be added with TMC-114 and Viread, and to see if Fuzeon is truly necessary. From the sound of it, and if you are still susceptible to an NNRTI, that can also be used in concert. Current data suggests that you need only at least one other susceptible agent with TMC-114 to get a significant response. All of my above stated options should not worsen neuropathy nor lipoatrophy. Thus, I highly doubt that Fuzeon is absolutely necessary for your situation at this time.

I just finished reading your article “Living With It: The Dating Game,” [March/April 2004]. My best friend came across it and sent me the link. I was awe-struck. It read like the conversations we have had! I’m 52 and he just turned 51. I’m poz and he’s got AIDS. My ex-boyfriend of three years is named Ken! Wow! Imagine that!

I just want to say bravo to the writer… and I wonder if my telephone conversations were “tapped!” Seriously speaking, it tugged at my heart in such a way that I wish there was a place/organization/group etc. here in Atlanta where I could have this conversation with others in my/that situation.

Thanks again for such a compelling and insightful article. I’m also glad to have found a new HIV/AIDS website.

Name withheld, via the Internet

I am writing to tell you thank you on behalf of the peer education program here at the Price Daniel Unit of the Texas Department of Criminal Justice prison system. Your journal has really been a very useful tool in helping to teach offenders how to protect themselves from HIV/AIDS and how or what to do in case of infection. Every time I get a new issue from you, people start lining up wanting to read it. People in here always want good, updated information on HIV/AIDS, and you do a really good job of providing this in your journal.

I am also writing you to ask for an address at which I can contact the Hope’s Voice organization (July/August 2006). You provided a Web address but no mailing address. Hope’s Voice sounds like a very good program, and I’d love to see more programs like this. In Texas we have a lot of young adults being locked up for long periods of time. It’s a sad but true fact and it seems to be getting worse as time goes on. Most of them are between the ages of 18–28 years old and come from lower income families. One good thing is they do seem to be the most interested group of people who want to take the peer education’s “Wall-Talk” class on disease prevention. They want to learn how to be safe in prison and when released. I was wondering if the Road to Hope Tour ever thought about possibly going in to a prison and talking to the offenders? To me this would be a great way to help a lot of young people, hopefully, become aware of HIV/AIDS and help them be more responsible upon release. Also, the article mentioned a video documentary of the tour—is there any way we could get a copy for our class?

Name withheld, Snyder, TX

Enid Vázquez responds: As of press time, Hope’s Voice did not answer an e-mail request for answers to your question (and there is no address listed on the organization’s Website).