The Ins and Outs of Gay Sex (21 page)

Nonnucleoside reverse transcriptase inhibitors represent a new and promising class of medications.
They bind to the enzyme reverse transcriptase, which changes viral RNA into DNA, and block this crucial stage of viral reproduction.
Although they work at the same step as nucleoside analogs by preventing the manufacture of viral DNA, their mechanisms of action are different.
The most common side effects produced by the nonnucleoside reverse transcriptase inhibitors are allergic skin rashes and gastrointestinal upset.

By late 1998 no nucleotide analogs had been FDA approved, although the time was getting close.
Like nucleoside analogs, these drugs also hamper the conversion of viral RNA to DNA, but their mechanism of action seems to be simpler.
Patients treated with the drug adefovir as part of clinical trials have noted nausea, diarrhea, and liver problems as the most frequent side effects.
Some men also experience kidney damage.
Adefovir requires only once-a-day dosing, but it reduces body levels of an essential substance called L-carnitine, requiring you to take supplements.

All antiretroviral drugs mentioned can have severe side effects that limit their effectiveness.
Fortunately, other medications treat these side effects (antidiarrheal medicines are frequently given with protease inhibitors), and dose adjustments make stopping medications rarely necessary.
Your doctor won’t know you’re having trouble handling a medication unless you speak up.
I have had patients whose viral loads soared when they stopped treatment precipitously because they couldn’t take the side effects or strict dosing requirements.
We know it’s hard to schedule power lunches around your medications and bowel movements.
Discuss your problems with your doctor so together you can adjust doses or try other medications until you strike that perfect balance between effectiveness and compatibility with your lifestyle.

Current recommendations for HIV treatment begin with a combination of multiple medications:
most often
one
protease inhibitor and
two
nucleoside analogs.
Again, this could have changed by the time you read this.
The vast majority of men treated in this manner see a dramatic drop in their viral load to undetectable levels.
Therapy is maintained until the viral load rises, a sign of emerging resistance.
At this point, most physicians switch you to three different drugs.
Even when all three drugs are changed, you may not respond as well as you did at first.
Your virus already possesses some resistance to nucleoside analogs and protease inhibitors from exposure to your original treatment protocol.
Single-drug substitutions may increase resistance and are ill advised unless done to lessen side effects or reduce dosing restrictions.
Attempts to cease all antiviral treatments in patients whose viral loads have fallen to undetectable levels have been unsuccessful thus far, resulting in rising viral counts and falling T-cell levels.

Before your doctor takes out that prescription pad and scribbles illegible instructions, you must have a thorough
understanding of the drugs’ side effects and restrictions they place on your lifestyle.
Do not allow your doctor to hand you a wad of prescriptions on your way out the door.
Know what you are taking and why.
If the schedule sounds intolerable or the complications too severe (especially if you already have an irritable bowel), ask about alternatives.

Know your viral load and T-cell counts.
I have treated HIV-positive patients who, out of fear, refuse to know their counts.
Your counts won’t improve just because you don’t ask, and this is not ostrich medicine where what you don’t know can’t hurt you.
It is better to have two watchdogs (you and your doctor) guarding your health.
If your doctor won’t answer questions or address your concerns, find one who will!

The relatively new treatment strategy of HIV prophylaxis involves taking drugs to try to prevent infection in one of two circumstances:
after unprotected sex with a suspected positive partner, or immediately upon finding out you’re HIV positive.
There is no medical evidence
yet
proving that infection can be aborted by prophylactic treatment in either case.
So far our best evidence that this may work comes from healthcare workers stuck with needles from HIV-positive patients; when aggressively treated with antiretroviral medications, they may not become HIV positive.
Research is ongoing to determine if this type of treatment is beneficial for all people (and we hope it is).
For now, many physicians recommend three-drug therapy for four to six weeks after unprotected anal sex with a known HIV-positive partner.
It must begin within twenty-four hours of exposure.
If you are still HIV negative at the end of treatment, most doctors advise stopping medications and repeating your HIV test regularly to see if you become
positive.
Prophylactic therapy must not be viewed as an alternative to safe sex!

We still don’t know whether patients who are placed on therapy immediately upon becoming HIV positive need to be treated for life.
Some researchers believe that hitting the virus hard and fast can eliminate it from your system.
Time will tell if this is the case.

The greatest threat from HIV is its progressive destruction of your natural immunity, which allows cancers and opportunistic infections (those that normally wouldn’t be able to harm you) to take hold.
Not only have great strides been made in attacking the virus itself, advances also have occurred in treating other diseases associated with HIV.
It is common for men with HIV to take medications that prevent opportunistic infections.
Table 5.
3
presents a list of the most common drugs used.
Numerous other medications are prescribed as needed to combat other infections.
They are beyond the scope of this chapter.

In addition to the prophylactic drugs already mentioned, you should be vaccinated against the following common diseases:
diphtheria and tetanus; mumps, measles, and rubella; influenza (repeated annually); pneumococcus; and hepatitis A and B.
Immunizations containing live virus or bacteria are
not
given except for measles, because the risk of infection is too great.
Most physicians advise HIV-positive patients against travel to those Third World countries that require numerous vaccinations prior to entry.

A little more than a decade ago, there was no specific treatment for HIV.
Now people are living longer and healthier
lives thanks to so many scientific advances.
Five years ago a typical HIV specialist spent most of the day in a hospital caring for desperately ill patients.
Now most rarely have to hospitalize their patients.
The future holds many exciting promises.
In addition to numerous other medications currently in various stages of development, research continues to determine how many antiviral drugs should be taken at one time—or if one combination is better than another.
Physicians also want to know if beginning treatment as soon as someone becomes HIV positive can wipe out the infection.

Scientists are also evaluating different tests that will, it is hoped, determine which drugs
your
particular HIV is resistant to.
This type of sensitivity test is done routinely for bacteria and helps doctors know which antibiotic to prescribe.
It still cannot be done effectively for HIV.
Currently when a physician prescribes medications for HIV, it takes weeks of monitoring your viral load to determine if the combination is effective or if your virus is resistant.
If your viral load doesn’t drop far enough, your doctor still won’t know if you’re resistant to just one or all of the medications.
Determining drug sensitivities would help tailor treatment to each patient.

And we still hope for a vaccine that provides immunity to HIV.
To date, creating this has proven an impossible task for many reasons.
In most viral infections, the virus doesn’t change as it moves from person to person.
But HIV constantly mutates, changing its appearance.
Any vaccine would have to provide immunity to all potential varieties.
A vaccine that gives immunity against one type of HIV might be ineffective against the one that infects you.

The search for a vaccine is also complicated by fear that immunization might cause the disease.
Even a weak strain (one that can’t harm you), once injected, might mutate to a more lethal variety.
Such was the case with a vaccine recently tried on monkeys.
All have developed AIDS from a supposedly harmless strain.

TABLE 5.
3
DRUGS USED TO PREVENT OPPORTUNISTIC INFECTION

Scientists are working with many different possible types of vaccines, from just using a piece of HIV DNA, to using an inactive virus, to using dummy particles that mimic the shape of HIV.
To date, no vaccine has progressed beyond early trials.
More research dollars and dedicated clinicians and scientists are needed to translate our hopes for a vaccine into reality.
A decade ago there was no treatment for HIV; I hope in a decade from now there will be no more HIV!

Although great strides have been made in HIV treatment, we still have a long way to go.
Increasingly, the virus is
becoming resistant to medications, and a good vaccine still seems a long way off.