Derek Thaczuk listens in while doctors and HIV patients put the latest
lipo research to work (differently) on their treatment plans
So
your viral load’s undetectable and your CD4s are high, but lately
a thinning face looks back at you from the mirror. Or maybe your lipid
levels have you worried about heart attacks—like someone twice your
age. What to do? If the boat’s not sinking, should you rock it? Is it
best to count your blessings and leave well enough alone?
Not
necessarily, say experts—doctors and HIVers alike. “If you have
concerns about lipo, you should discuss them with your doctor,”
according to Paul Sax, MD, of Brigham and Women’s Hospital in Boston.
“We’re all after the same thing, and that’s choosing the best HIV
treatment regimen. ‘Best’ doesn’t just mean potent enough
virologically—it means least toxic, too.”
Switching off meds,
even if they’re known to have lipo risks, may be counterintuitive for
some, given the importance of taking HIV medication on time, every day,
as directed to avoid drug resistance. But, according to Dr. Sax, “As
long as your viral load is suppressed, and the new drug is going to be
effective, swapping isn’t going to cause drug resistance.”
A change for the better Of
course, all meds are not created equal when it comes to lipo—and
several are stepping way out in front lately. Studies show that
ditching Zerit (d4T) for Ziagen (abacavir) can help halt or even
reverse facial thinning, and earlier this year, British researchers
proved Viread (tenofovir) to be as attractive an alternative. In Graeme
Moyle’s Randomised Abacavir Viread Evaluation (RAVE) study, patients on
Retrovir (AZT) or Zerit were randomly switched to either Ziagen or
Viread. After 48 weeks, both groups had regained similar amounts of fat
in their limbs and cheeks. The researchers found that facial gains were
“similar to the effect observed [with] a standard collagen treatment.”
A
switch may also do the trick for knocking down cholesterol levels. Many
protease inhibitors can boost lipids (fats) to heart-harmful levels in
the bloodstream. In the Switch Atazanavir (SWAN) study, patients on
protease inhibitors (PIs) either stayed on the same meds or switched to
Reyataz (atazanavir). By 24 weeks, fat and cholesterol levels improved
significantly in those who switched to Reyataz. Just as crucially, HIV
remained in check—in fact, viral loads remained suppressed longer in
the group that switched.
When doc’s not onboard If
you find the science encouraging, you’re not alone—but you’ll need your
doctor onboard to take it from there. For patients who are eager
to make adjustments to their treatment regimen but find that their
health care provider is not budging, try this: Ask for an
explanation—and address each concern. But also try figuring out what it
will take for your doctor to feel comfortable with a switch: More
careful monitoring? A statement releasing him or her from liability?
For some HIVers, of course, it may simply be time to find a new
doctor—one whom you “interview” about treatment philosophy first.
Judith
Currier, MD, of the UCLA CARE Center, believes that when switching
meds, “Caution is healthy,” and that, of course, it’s flat-out unwise
to jump to a drug you might be resistant to or that could lead to
adherence problems. “But if it represents an improvement to your
therapy, then it’s something that should be discussed.”
Strategy No. 1 Brian DiCrocco got implants and switched meds, too
Brian
DiCrocco, a 37-year-old community activist who lives in San Francisco,
feels he’s largely won his fight with lipo. When he quit his first
regimen—Zerit, Epivir (3TC) and Viracept (nelfinavir)—in 2002 for
the single-pill, triple-nuke option of Trizivir (abacavir + AZT +3TC),
it wasn’t just because of Vira-cept’s gut-loosening effects. “I was
starting to really notice some hollowing in my cheeks,” he recalls.
“You try so hard to adhere to your meds. And then when you see the
looks, sometimes you can’t help thinking, ‘Why am I trying?’ ”
DiCrocco’s
face continued to thin for about a year after the med switch; in fact,
for Brian, it was Sculptra facial filler (see “Lipo Fix-Its,” page 8)
that really turned the tide. “I can’t say enough good things about it.”
But his facial implants had a supporting cast: “I’m sure that if I
hadn’t switched the meds, things would not have improved so much. I
look 100% better and don’t feel like I’m fighting a losing battle any
more.”
Strategy No. 2 Derek Thaczuk found that refining his combo was enough “About
two years ago, I had to make a very quick decision about whether to
swap Zerit for Viread. Hesitating could’ve meant losing insurance
coverage. My face was getting gaunt; an inquisitive aunt was asking
awkward questions. But because my history is thick with drug
resistance—I’ve been positive since 1992—I counted myself lucky to have
an undetectable viral load. (It had taken a three-year pileup of
Epivir, Zerit, Videx [ddI], Kaletra [lopinavir + ritonavir] and Sustiva
[efavirenz] to get me there.) So my primary care doc, my HIV specialist
and I put our heads together. They were satisfied that my resistance
profile held no red flags for Viread. And I was willing to trade the
devil I knew for the devil I didn’t—as long as my viral load wasn’t at
stake. I’m happy to say that it all paid off. My HIV’s still
suppressed, and my aunt is finally raising eyebrows about my haircuts
instead of my sunken cheeks.”
Hard Questions Q: Why would anyone want to take HIV meds if it means running the risk of lipo?
A:
Because untreated AIDS is still a deadly disease. “If I were really
blunt, I’d say: ‘If you’re afraid of how you might look on meds, you
should see what you could look like without them,’ ” says Brian
Cornelson, MD, staff physician at Toronto’s St. Michael’s Hospital. “Of
course, I don’t really word it that brutally, but the fact is, we’re
still dealing with a very serious illness.” Judith Currier, MD, expects
med fears to drop when the prevalence of lipo itself drops—which she
figures will come with greater reliance on low-lipo drugs.
Q: Why would you stick with a drug that’s distorting your body?
A:
Maybe because you’re glad to be alive—and because there’s only so much
you can switch or fix. Take Elizabeth Perez, 52, from New Jersey. A
swollen trunk and severe “chicken legs” haven’t swayed her off
antiretrovirals. A surgeon removed four pounds of lipo from her back
last year, but she has endured the rest for reasons that haven’t much
changed. “I don’t want to look like this,” she says, “but then I think
of all the people we lost in the ’80s, who never got a chance at the
medications we have now. I don’t think this would be a tough decision
for them.”
