Ask Dr. Joel: Questions about HIV and AIDS

I'm Joel Gallant, an HIV doctor now at Johns Hopkins University in Baltimore and AXCES Research & Health in Santa Fe. During the 6 years I spent at Gilead Sciences, I shut this forum off, but now that I've retired from Gilead, I've opened it up again. Readers can post questions about HIV and AIDS, keeping in mind that the purpose of the Forum is not to give medical advice, or to be a substitute for your interactions with your own health care provider. The views and opinions expressed on this blog are my own, and do not reflect the views of my employer.

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So long, farewell

They say all good things must come to an end.  I’m sad to announce that I’m shutting down the HIV Forum. In October I’ll be taking a new position as a senior director in Medical Affairs at Gilead Sciences.  I’ll be involved in medical and scientific education, both domestically and globally, and will be participating in Gilead’s continued HIV drug development. As a Gilead employee, it would be inappropriate for me to be providing answers to your questions—especially answers that might be misconstrued as medical advice.

I’ve been conducting Q&A forums for more years than I can count: first at The Body, then on the Johns Hopkins website, and more recently on this Tumblr blog. I like to think that I pioneered this approach, since there wasn’t really anything like it—at least in HIV—when I started answering questions at The Body. As one of my few creative outlets, this has been a lot of fun for me, and I hope it’s been both helpful and entertaining for you.  I’ll keep the blog up for a while—without answering any more new questions—but at some point I may have to take it down completely (if that’s even possible), since the answers will become increasingly dated.

On a happier note, the 4th edition of my book, 100 Questions and Answers about HIV and AIDS should be out soon.

There are lots of other great ways to educate yourself about HIV.  In fact, I just posted a few suggestions in an answer to a recent question. “Knowledge=Power.”  My best to you all.

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Dr.Joel I have a question about Milk Thistle I have had no luck finding a answer to. Can you take it while taking genvoya?

You can’t find an answer because the interaction has never been studied. There is the potential for interactions with drugs that use the liver’s cytochrome p450 enzyme system, which includes two of the components of Genvoya. On the one hand, I could tell you that it’s probably safe. On the other, hand, it might not be, and there are no proven medical benefits of milk thistle.

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Can you you share some news from Paris conference you find exciting?

I can do better than that: I can refer you to Paul Sax’s blog. He was clearly paying more attention than I was!

http://blogs.jwatch.org/hiv-id-observations/index.php/really-rapid-review-paris-ias-2017/2017/07/30/

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So my boyfriend is HIV-positive, we've been dating for about 6 months now and I got tested for HIV after about 4 months and it came out negative. My boyfriend is undetectable and I'm currently working on getting PrEP. I was wondering because of the evidence from the PARTNER study, is PrEP really necessary for our situation? I mean I do like the mental reassurance that I'm safe not using a condom but what do you normally recommend for serodiscordant couples in this situation?

I’ve answered this question many times in the past, but it’s been a while. Most experts consider PrEP “overkill” when an HIV+ partner has an undetectable viral load on ART, since there have been no reported cases of transmission in such relationships. I would recommend PrEP if you were having sex with other partners or if you weren’t certain of your partner’s adherence to therapy,.

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Can you recommend some good web resources for educated news and discussion on HIV and related ID developments? I follow Dr. Sax's blog, which is great. I follow you, but a lot of your questioners ask weird questions (not your fault!). I have an undergrad degree in biochem, but I am otherwise a lay person (a *gasp* lawyer, actually), I do not want to purchase access to professional journals, and the MSM-outlets and investor publications are a little thin on substance. What's out there for me?

Here are just a few to get you started:

Positively Aware:  https://www.positivelyaware.com/

HIV Insight at UCSF: http://hivinsite.ucsf.edu/

Project Inform: https://www.projectinform.org/

Clinical Care Options: https://www.clinicaloptions.com/hiv.aspx

The Body: http://www.thebody.com/

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Hello chief, I read somewhere that because HIV patients infected with transmitted drug-resistance virus do not have a reservoir of drug-susceptible virus, drug-resistant virus is only replaced by drug-susceptible virus by "back-mutation", a process that can take years. What is "back-mutation"? Thank you!

This means that the virus mutates “backwards,” from the transmitted mutant form to the “wild-type,” non-mutant version that circulates in the community. However, even with back-mutation, you should still  assume that some mutant virus persists in latent reservoirs.

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I was switched from Truvada/Ticicay to Triumeq bc of low gfr in kidneys and there was no substantial change a year and a half after the switch. I recently saw a 15 point increase in gfr and the only change I made was stopping multivitamins. My question is to you: Can the multivitamins have been causing my low gfr?

Multivitamins, taken at normal doses, would not affect kidney function or eGFR.

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Dr G, my triglycerides are high and good/bad cholesterol out of whack. I mentioned The Intrepid and Reprieve studies and wondered if I should go on a statin and he said "oh, ID doctors don't do that. Your GP should prescribe that, I only monitor HIV levels. What is your feeling about an HIV specialist managing more than the virus?

Some HIV specialists provide primary care for their patients, in which case this would be something they would do. Others provide only HIV care and leave primary care issues to the PCP. or GP.  If your HIV specialist believes that there’s no reason to be more aggressive with statins in HIV+ people than in the general population, then I can  see why he’d leave this to your GP. On the other hand, if he believes there’s a reason for more liberal use of statins based on HIV infection itself, then he would either prescribe the statins or communicate his recommendation to the GP.

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Hi Joel, does being + increase the risk of having a UTI? I ask because for the last few weeks I have had a UTI and despite 4 seperate courses of antibiotics I've not been able to shift it. Thanks Mike.

Mike, HIV doesn’t increase your risk of UTI, but UTIs are unusual in men. Maybe you’re treating the wrong condition. The more common infectious causes of urinary symptoms in men are urethritis (especially gonorrhea and chlamydia) or prostatitis.

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You kindly ans'd my last ? on 6/30. I am the one the Doc has put on drug holiday. I'm now in month 4 of my labs coming back UD, and all other levels normal. I have tested Negative on 3 OTC antibody tests. I told my doc that you said "in isolation, a VL of 400 could be a false positive." He does not understand that. He says that once there is documented viral load, it cannot be a false positive. I am having an ELISA in 2 days. Do you have any language I can give my doc? DX 2013, well documented.

See link below: 

http://nccc.ucsf.edu/2016/06/24/case-of-the-month-false-positive-hiv-viral-loads/

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Thanks for your time! I was diagnosed in December 2016, have had a undectable viral load since Jan/Feb. I read online about the benefits of mixing garlic cloves, organic honey, organic apple cidar vinegar and drinking. I am currently taking descovy and isentress. Am I ok with drinking that? My Dr did not really know

This has obviously never been specifically studied, but what you’re describing is food. There aren’t many foods you can’t eat while taking antiretroviral therapy.

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Hello Dr, i recently switched from atripla to genvoya. I am taking genvoya daily at 2 pm with lunch but i want to change the time till 8 pm with dinner. does this put me at risk of resistance? I decided to make this change gradual that is taking genvoya one hour late every day until i reach the 8 pm goal and then start taking it daily at 8 pm. please advise, thank you

You can just make the change. Antiretroviral agents today aren’t so fragile as they were in the 90′s.  It doesn’t matter when you take them, as long as you take them.

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Hi Dr. Gallant. It won't be long until my fall allergies start to act up. Is it okay to take darunavir, Genvoya, Livalo, Lipitor, Zyrtec, and sometimes Benadryl together? No significant interactions? No rotten side effects? Thank you.

I wouldn’t take both Zyrtec and Benadryl at the same time.  Pick one or the other: either a sedating antihistamine (Benadryl) or a less sedating one (Zyrtec). Otherwise the combination is OK.

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I have been HIV+ over one year and on Triumeq. UD and lowest CD4 500. I have read about various intestinal issues that can come from the depletion of beneficial bacteria (from either the virus or the meds). Lately I have had a significant increase in intestinal gas. At times there is discomfort in my lower left colon area due to the build up of the gas. I have no trouble passing gas and that relieves the pain, but there is a lot. My diet has not changed. Any suggestions on how to approach this?

I doubt that your gas has anything to do with the HIV-related intestinal issues you mention. It’s possible that it’s medication related, or it could be a diet issue. You could try taking a simethicone-containing medication such as Phazyme or Gas-Ex.  Or you could find a job where it doesn’t matter: you could become a forest ranger or lifeguard.

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I hear a lot people saying that the cure wasn't found yet because the "big pharma" is making money selling medicines. While I don't discard this as a partial reason, HIV+ people on treatment can live a normal life by just taking their medicines (versus other chronic conditions like diabetes or arthritis for example), so there isn't as much of an urgency as in the 80s/90s. What do you think about that? Also, what could improve in the current ART - other than their cost? Thanks.

“A lot of people” are wacko conspiracy theorists.  Here’s what I have to say about that absurd notion in my book: 

Isn’t it true that drugcompanies are withholding the cure to make money?

Thisis a popular point of view among conspiracy theorists and those with contemptfor drug companies, but a little rational thought should put this myth to rest.

1. It’s no surprise that we haven’t yet curedHIV infection. The difficulty of finding a cure is discussed in Question 42.

2.  People who develop therapies atdrug companies are scientists. They’re motivated by the things that motivatescientists everywhere else: publication in prestigious journals, the respect oftheir colleagues, Nobel Prizes, TV interviews, getting funding to do moreresearch, and the knowledge that their work has made a difference to humankind.No scientist who discovers the cure for AIDS is going to keep quiet about it,even if ordered to do so by some evil, profit-hungry CEO!

3. Drugcompanies are competitive. If they’re onto something big, their competitorscan’t be far behind. No company strives to be the second company with The Cure. If a company had a cure, you’d haveheard about it!

4. A cure for AIDS will be highly profitable. Sure, there’sprofit in lifetime therapy, too, but it’s shared among multiple competing drugcompanies and doesn’t last forever. Drugs go off patent and get replaced bygenerics; they fall out of favor as they’re replaced by newer and betteragents. Look at hepatitis C, where a cure originally cost around $100,000.  A cure for HIV is likely to be even moreexpensive. Shed no tears for the pharmaceutical industry when we have a cure.It will be highly lucrative for the company that develops it.

5. Mostconspiracy theories are wrong.

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Hello Dr Joel. I am on Complera for 3 years. My labs 6 months ago came out CD4 700, UD (as all previous before that) and my labs a week ago came out CD4 800 an VL about 4K. Rest of blood work normal. My doctor is confused and ordered another VL with results expected in about 2 weeks. Meanwhile recommended staying on Complera. I am 100% adherent, no baseline resistance, take meds with my meal, no antacids or acid lowering drugs taken. Any thoughts? Are there any decent options to switch to?

It sounds like you’re doing everything right, which means this viral load is probably a false alarm.  If it turns out to be real, you should get a genotype. There should be plenty of good options.

Two weeks for a viral load???

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Hi dear Dr. Joel. My boyfriend who is positive UD cheated on me with someone else without a condom. We are about to try again to regain trust. If he got a resistant hiv strain, how long should we wait to perform a viral load test to know if he is no more undetectable? (know if he really got a resistant virus). Whats the main std tests that you usually ask to your patients? I want to be sure to get back to have intimancy without condons again. Thank you very much for your help.

The risk to you from your boyfriend’s infidelity is not HIV infection. In people with undetectable viral loads on ART, superinfection with a resistant virus resulting in virologic failure--if it happens at all--is extremely rare.  It’s probably more of a theoretical risk than a real one.

The risk to you is transmission of an STD. Standard STD testing includes a blood test for syphilis and a urine sample, throat swab, and rectal swab for gonorrhea and chlamydia.