In each issue, POZ publishes a different standard of care, a guide by which people with HIV and their care providers can make personal choices about health care regimens. HIV standards of care differ by region, treatment philosophy and patient population.
Pneumocysitis carinii pneumonia (PCP) -- whose symptoms can include fever, fatigue, night sweats, chest tightness and a brutal cough -- remains one of the biggest killers of people with AIDS especially in communities of color. But for years, drug prophylaxis (prevention) has been reducing its incidence and extending survival. According to U.S. Public Health Service guidelines, prophylaxis should be initiated (and maintained for life) for any HIV positive person with: 1) a CD4 count below 200; 2) a prior episode of PCP; or 3) oral candidiasis, unexplained fevers or other major symptoms. San Francisco treatment education and advocacy group Project Inform adds the categories of anyone with: A CD4 percentage below 15; a previous opportunistic infection; or current use of chemotherapy. Because some PCP cases occur between 200 and 300 CD4 cells, Project Inform recommends that people in that situation discuss with their physician whether their overall bloodwork, symptoms or risk factors justify beginning prophylaxis.
Federal guidelines designate TMP/SMX as the clearly superior drug, with dapsone as second-line and aerosol pentamidine (AP) third-line therapy. (All three are also used in treatment of acute PCP, although pentamidine for that purpose is injected or used intravenously. Atovaquone, an approved PCP treatment drug, is now under study for prophylaxis.) To increase effectiveness, some physicians recommend adding AP to one of the oral drugs when CD4 cells fall below 100 or after a PCP bout.
Because a high proportion of PWAs are allergic to TMP/SMX, doctors have designed a desensitization protocol (See Standard of Care, POZ No. 5) which acclimates the body to gradual increases in dosage (using a liquid formulation). This should only be used under a physician's supervision. One study shows that 85 percent of those allergic to the drug can be successfully desensitized.
If you choose TMP/SMX or dapsone: 1) check into the numerous drug interactions that can cause problems, most commonly with AZT and ganciclovir; and 2) note that many nutritionists advise daily intake of acidophilus (a form of beneficial bacteria available at health food stores and buyers clubs) to restore intestinal balance. Since evidence suggests that low glutathione levels can increase adverse reactions, some nutritionists also recommend glutathione-generating antioxidants such as Vitamin C, alpha-lipoic acid, L-glutamine (an amino acid) and N-acetyl-cysteine (NAC, a supplement approved in Europe to treat bronchitis).