General Advice

Get Dental Care

The dental problems common to all adults—diseases of the teeth and of the supporting structures of the teeth—seem to occur more frequently and more severely in people with HIV infection.

Follow a Nutritious Diet

Nutrition is important for virtually all people with HIV infection for two reasons. The first is that weight loss is a common symptom of this in­fection, and during the later stages, many people lose weight excessively. Paying attention to nutrition early in the course of the infection might delay weight loss. The second reason is that good nutrition may help maintain a strong immune system, even apart from HIV infection. It is well established that the immune system functions less well in people who are malnourished, though malnutrition must be severe before im­mune defects become noticeable.

Malnutrition is more exactly called “protein-calorie malnutrition.” Calories come from most food, particularly fats. Proteins come from meat, milk products, poultry, eggs, fish, and dried beans and rice. Peo­ple need diets that balance calories, protein, and the necessary vitamins. The usual balance for a healthy person is about 50 percent carbohydrate, 20 percent protein, and 30 percent fat, with an ample supply of vita­mins. Some people with uncontrolled HIV infection need more calories because HIV infection seems to increase their metabolism: a person with untreated HIV infection requires 2,700 to 3,600 kilocalories per day. People with HIV infection consequently need to eat more. But excessive doses of vitamins, and macrobiotic diets or other fad diets, should be ei­ther avoided or undertaken only with the advice of a certified dietitian.

Get Exercise

Exercise programs are widely advocated as a way of staying healthy and of preventing cardiovascular disease. Whether exercise is similarly help­ful to people with HIV infection is unknown. “Progressive resistance” exercises, like weight-lifting, when combined with eating enough calo­ries, do increase lean body mass. Exercise will not increase CD4 cell counts, but most people who exercise regularly also feel better both physically and emotionally. There is no reason for a person with HIV infection to avoid regular exercise as long as fatigue or other symp­toms do not prevent it. Strenuous exercise like marathon running and Olympic-type training, however, may actually be deleterious to the im­mune system. For example, Olympic athletes competing in endurance events have more colds and other infections. The implication is that ex­ercise in moderation improves the sense of well-being, while intensive physical training may be hard on the body.

Stop Smoking—How to Do It

Smoking is bad for health in many ways. It is especially bad for the health of people with HIV infection. HIV predisposes people to lung in­fections; smoking also predisposes people to lung infections; and stud­ies of people with HIV infection show that smoking causes even more lung infections. Before HAART, people often said that smoking was ir­relevant because HIV would kill you anyway. HAART has changed that. As people have benefited from HAART and lived longer, they have be­come more likely to get sick or die from other conditions.

The major risk of smoking is cardiovascular disease. HAART ther­apy also carries a risk of cardiovascular disease, because of the effect that the drugs—especially the protease inhibitors—have on blood lipids, that is, on LDL cholesterol and triglycerides. These side effects can be mea­sured and treated. Compared to protease inhibitors, smoking is a much greater risk. The second major risk of smoking is lung disease; it’s almost a given. The risk of lung cancer increases with time and with the num­ber of packs smoked per year.

Nicotine is one of the strongest addictions, and the effects of its with­drawal are harsh: tension, sleep problems, agitation, and depression. Many of the methods available for stopping are based on the science of nicotine addiction and the psychiatric effects of nicotine withdrawal. The key to stopping is motivation: you have to really want to stop. Many peo­ple stop on their own; others need medical help. The treatments come in two forms: nicotine replacement and non-nicotine therapy.

Nicotine Replacement

All of these methods have been reviewed by the FDA, which has de­termined them to be safe and effective. Which method you choose de­pends on your own preference.

• Nicotine patch: patches are available in doses based on the per­son’s weight or the number of cigarettes smoked per day. The initial dose is taken for 4 weeks, then decreased every week for the next 4 weeks. The advantages of the patch are that it is easy to use and can be obtained without a prescription. The disadvantage is the lack of good dose control.

• Nicotine gum: doses are 2 mg if you smoke fewer than 25 ciga­rettes per day, and 4 mg if you smoke more. You chew one piece of gum per hour for 8 to 12 weeks. The advantage is that you can con­trol the dose and you don’t need a prescription. The disadvantages are the necessity of chewing correctly, the fact that you can’t eat or drink while chewing, and the possibility of dental damage.

• Nicotine lozenge: the dose is a 2 mg lozenge for fewer than 25 cig­arettes per day and a 4 mg lozenge for more. The lozenges are taken every 1 to 2 hours while awake for 6 weeks, then every 2 to 4 hours for the next 3 weeks, then every 4 to 8 hours for another 3 weeks, and then when necessary for 3 months. The entire process takes 3 to 6 months. Occasional side effects are headache, heartburn, nau­sea, and cough.

• Vapor inhaler (Nicotrol Inhaler): Cartridges are inhaled like a cig­arette, to simulate smoking. The regimen is 6 to 16 cartridges, used over 3 to 6 months. These may cause throat irritation and cough, and the device is obvious to others when used.

• Nicotine nasal spray (Nicotrol NS): A 1 mg dose of nicotine is taken as a nasal spray, half in each nostril, once or twice an hour over 3 to 6 months. This delivery system replaces nicotine rapidly, and the person using it controls the dose, but it is also the most ir­ritating: it causes irritation in the nose, coughing, sneezing, and tears. Most people learn to tolerate these effects with continued use.

Non-Nicotine Therapy

• Bupropion (Wellbutrin SR or Zyban): This is an antidepressant that has been found to be effective for stopping smoking. It is the only drug in its class approved by the FDA for stopping smoking. Authorities consider it as effective as the nicotine replacement meth­ods. Treatment should start a week before stopping smoking. Use the sustained-release (SR) formulation. The dose is 150 mg per day for 3 days, then 150 mg twice daily. Most people take the drug for 7 to 12 weeks, sometimes as long as 6 months. The advantage of bupropion, compared to the nicotine replacement strategies, is the lack of exposure to nicotine. The disadvantages are the side effects of bupropion: insomnia, nausea, weight loss, dry mouth, and agita- tion—and, in 1 person in 1,000, seizures that are dose-related and are very rare at these smoking-cessation dosages.

• Nortriptyline (Aventyl, Pamelor) and clonidine: These are two other antidepressants that may be used but have not been reviewed by the FDA for stopping smoking; they are generally considered “second line” treatments.

Keep Working

People with HIV infection should work because working contributes to people’s sense of self-worth, to their knowledge that they are contribut­ing members of society. HIV infection should not keep people from working unless fatigue or other symptoms make it impossible.

Occasionally employers have used the fact of HIV infection to limit workers’ employment or to change their job assignments. The employee has considerable legal recourse as a result of the Rehabilitation Act of 1973, which became law in the United States in July 1992. This law pro­tects every citizen against unfair discrimination based on sex, race, or handicap. Under this law, HIV infection is a handicap, and those who have HIV infection are legally protected. The employer must provide the employee with continued employment in the same job as long as she or he is capable of performing the job. This issue is discussed in more de­tail in chapter 9.

Know Your Travel and Occupational Risks

Travel Risks. The greatest health risk to people with or without HIV infection is travel in developing countries, where the major problem is microbes that contaminate food and water. Avoid raw fruits and veg­etables, raw or undercooked seafood or meat, tap water, ice made from tap water, unpasteurized milk and dairy products, and all food or drink purchased from street vendors. Preferred foods are steaming hot: hot tea or coffee, or meat that’s well-cooked. Also safe are peeled fruit, bottled beverages, and anything with alcohol in it. Water may also be treated with iodine or chlorine, but this is not as effective as a rolling boil for one minute.

Most diarrhea in travelers is easily controlled, and access to good health care may be difficult to obtain, so some travelers carry antibiotics to prevent infections during travel to developing countries. Most travel­ers need not do this, but some people with HIV infection may be con­sidered at high risk. A common recommendation is for ciprofloxacin (Cipro) or a related drug. Travelers to developing countries should take along two types of antidiarrheal medications.

Vaccines are often required or recommended for travel. The general rule for people with HIV infection is that they not receive live virus vac­cines. For typhoid fever, get the injected inactivated vaccine, rather than the form taken by mouth. For yellow fever, the only vaccine is a live virus vaccine whose safety in people with HIV infection is uncertain. If you need to travel to an area with yellow fever, you may need to obtain a let­ter waiving the usual vaccine, and you need to avoid mosquito bites. Killed vaccines—standard diphtheria-tetanus (Dt), rabies, and Japanese encephalitis vaccines—are not a problem.

Travelers need to be aware of the types of infectious diseases in var­ious areas. Many developing countries have high rates of tuberculosis; people with HIV infection are over 100 times more likely to get tuber­culosis than people without HIV infection. Many areas also have high rates of malaria: the standard precautions are to avoid insect bites and to take certain preventive drugs that should be no problem for someone with HIV infection. Many tropical countries have visceral leishmania­sis, a disease transmitted by sand flies, that can be a major problem in people with HIV infection. Despite all these warnings, the claim that travel is too dangerous has relatively little support. Even if you are in the late stages of HIV infection, simply take common-sense precautions.

Occupational risks. The occupations that pose risks to people with HIV infection are those in the fields of health care and child care, and occupations that require animal contact. In the health care field, the ma­jor risk is of tuberculosis. This risk applies as well to employment in cor­rectional facilities and shelters for the homeless. The amount of risk of tuberculosis depends on the activities of the employee or volunteer and the prevalence of tuberculosis in the community. Among providers of child care, the major risks are of exposure to Cryptosporidium and, to a lesser extent, cytomegalovirus, hepatitis A, and giardiasis. These risks may be reduced substantially just by good hygiene.

Occupations requiring animal contact include veterinary work and employment in farms, slaughterhouses, and pet stores. The major risks are of infection by Cryptosporidium, Toxoplasma gondii, Salmonella, Campylobacter, and Bartonella. There is no good evidence that these oc­cupations carry much of a risk. Only be aware of the risk and use ap­propriate precautions.

Maintain Mental Health

HIV infection carries a psychological burden, both because of the nature of the disease and because of society’s reaction to it. One aspect of this burden is that people are often sensitized to their health and have an un­derstandable tendency to overreact. People with colds may conclude that they have pneumonia, a forgotten appointment may be interpreted as dementia, and a newly discovered freckle raises fear of Kaposi’s sar­coma. The fact is, most colds, mood changes, forgotten appointments, and freckles are normal. People with HIV infection have the same triv­ial medical conditions as anyone else. The average person develops three colds and one case of infectious diarrhea a year; over 90 percent of the general population has occasional headaches. The great majority of these common medical conditions are of no importance to the person with HIV infection. For people with HIV infection, a certain amount of depression is also normal. Most depression is situational; it’s the normal psychological response to adverse conditions. Some people, however, be­come extremely depressed. Their psychological burden becomes inca­pacitating; some may even consider suicide. These people would do best to consult a psychologist or psychiatrist.

Methods of maintaining mental health will differ with different peo­ple. Resources available include mental health professionals (psychia­trists, psychologists, and social workers), support groups, and AIDS- advocacy organizations. Mental health and the methods of maintaining it are discussed in chapter 4 and in chapter 11.