TREATMENTBULLETINAcomprehensiveguidetohealthandwell‐beingforpeoplelivingwithHIV/AIDS

November2011

CONTRAINDICATIONS,INTERACTIONS,&HIV:

WHATYOUNEEDTOKNOW

TorontoPeopleWithAIDSFoundaMonwww.pwatoronto.org

Disclaimer: The Treatment Resources Program at the Toronto PeopleWithAIDSFoundaMonprovidesinformaMonandresourcestoempowerpeople living with HIV/AIDS to be proacMve around their health byworking in partnership with their health care providers. We do notrecommendorpromoteanytreatmentinparMcular. Westronglyurgethose interested in any specific treatment to consult awide range ofresources,includingaqualifiedmedicaland/orcomplementarytherapypracMMonerwhohasexperienceinworkingwithHIV+individuals.

Permission to Reproduce: This document may be reprinted in itsenMrety for non‐commercial purposes without prior permission, butpermissionmustbeobtainedtoeditorotherwisealteritscontent.Thefollowingcreditmustappearonanyreprint:

ThisinformaMonisprovidedbytheTorontoPeopleWithAIDSFoundaMon(PWA).FormoreinformaMon,contactPWAat

416.506.1400.

TABLEOFCONTENTS

FOOD

AddedSugar

FatsandOils

RawFoods

Grapefruits,PomelosandSevilleOranges

MEDICATIONS

SUPPLEMENTS

St.John’sWort

Garlic

Echinacea

LIFESTYLE

Sleep

RecreaMonalDrugs

VaccinaMons

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4‐5

5

6

6

6

7

7

7

8

8‐10

10‐11

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Informa;on aboutHIV can be confusing. From transmission to treatment, therecanbeawholenewsetofdo’sanddon’tstoconsiderwhenHIV+,andtryingtosortthemoutcanseemtobeaherculeantask!Isthereanythingyouneedtoavoidnowthatyouare livingwithHIV?Are thereany interacEonsbetweenyourmedicaEonsandanyherbalorvitaminsupplementsyoumayhavebeentaking?Aretherethingsthatyouneedtobeawareofwhiletryingtostayhealthy?

ThistreatmentbulleMnisintendedtoprovideyouwithanoverviewofsomeofthethingsyouneedtobeawareofifyouarelivingwithHIV.ThisbulleMnisnotabletocovereveryinteracMonorcontraindicaMon,soalwaysbesuretocheckinwithyourhealthcareproviderifyouhaveanyquesMons,concernsoraretakinganythingnew.Most of the suggesMons in this bulleMn apply to the general populaMon as well,however,theymightbeofincreasedimportanceinpeoplewhoseimmunesystemsareweakened.

You’reprobably thinking–Seriously?Do Ihave tostartavoidingmy favorite foodsnow? RestassuredthefoodrestricMonswithHIVareminimalandmostlyrelatetomedicaMonuseandfoodsafety.

It is importanttokeepeaMngawell‐balanceddiettoensurethatyouaregeengawiderangeofnutrientstokeepyourbodyhealthy. Wholegrains(e.g.,brownrice,wholewheat, oats, barley), vegetables, fruit, and healthy proteins (e.g., fish, leanmeats, tofu, beans) are all important for providing the nutrients that your bodyneedsinordertokeeptheimmunesystemfuncMoningwell.There are some things that you should bemore conscious of, however. While itdoesn’tmeanyouneedtocompletelyavoidallofthese,youshouldtrytomoderatetheirconsumpMon.

Consuming excess amounts of sugar has been shown to negaMvely affect thefuncMoningoftheimmunesystem.Itcantemporarilyaffecttheabilityofyourwhiteblood cells to engulf bacteria and, overall, weaken your body’s resistance toinfecMons.

Addedsugarsaresugars thatdonotnaturallyoccur,but rather,areaddedto foodduringpreparaMonorprocessing . Someof thebiggest culpritsofaddedsugar inyourdietincludesugarydrinkssuchassodas,sportsdrinks,andfruitjuices,aswellsweetenedbreakfastcereals.

FOOD

AddedSugar

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Don’tbe fooledby the typeof sugareither–when lookingat the ingredients list,sugarcanappearinmanydifferentforms. Lookfortheseonthelabeltodeterminewhether a food contains added sugar: brown sugar, cane juice and cane syrup,glucose, dextrose, fructose, sucrose, syrup, lactose,maltose, raw sugar, molasses,invert sugar, honey, high‐fructose corn syrup, granulated white sugar, fruit juiceconcentrate,confecMoners’sugar,cornsweetenerandcornsyrup.

You can easily get a senseof howmuch sugar is in anyproduct by looking at thenutriMon facts panel that is located on the label. Four grams of sugar isapproximatelyequivalenttooneteaspoonofsugar.Yourtypicalcanofsodacontainsabout40gramsofsugar.Thismeansthattherearejustabout10teaspoonsofsugar(40/4)inonecan!

Thisguidelineshouldn’tonlyapplytothosewithHIVbutto everyone. With HIV infecMon however, evidence isshowing that the body ages faster because of persistentinflammaMon causedby the virus, puengyouat risk forheartdiseaseandotherchronicdiseasesatanearlierage.Certain HIV medicaMons also increase your risk ofdeveloping heart disease by increasing the level of fatsandcholesterolinyourblood.

FatsandOils

When reading labels try to keep trans fat and saturated fat as low as possible.Saturatedfatistypicallyfoundinanimalsourcessuchasmeatanddairyproducts.TransfatsarecreatedwhenliquidoilsaremodifiedtomakethemmoresolidinaprocessknownashydrogenaMon.

Trans fatsareespeciallybad foryouas they increaseyourbadcholesterol, loweryourgoodcholesteroland increaseyourriskforheartdisease,stroke,andtype2diabetes. They are foundprimarily in fried foods andbaked goods and you canalways find informaMon on howmuch trans fat is in a product on the nutriMonlabel.Ideallyyourintakeshouldbeasclosetozeroaspossible!

Try to sMck to healthy, unsaturated fats such as olive, canola, and safflower oils,avocado, nuts and seeds, and faly fish such as salmon, mackerel, herring, andtrout. ThesefatscanhaveaposiMveeffectonyourhealthandloweryourriskofheartdisease.

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Certain raw foods contain bacteria and parasites that can cause infecMon. Theseinclude undercooked or raw eggs, oysters, sushi, and very rare or raw meats.Whether you decide to avoid these is up to you, andmany peoplewho areHIV+conMnue to enjoy these foodswithout any concerns. Youmay decide to restrictthese foodsbasedon the statusof your immune system, for example if yourCD4countislow.

Whilemostpeoplewouldbeabletofightoffanybacteriaorparasitesthatmightbepresentinthesefoods,thosewithdepressedimmunefuncMonmighthaveaharderMmedoingso.

RawFoods

Grapefruit,PomelosandSevilleOranges

There is a significant interacMon betweenthe anMretroviral drug Saquinavir (aprotease inhibitor), cholesterol and othermedicaMons and grapefruit, including thejuice.Certaincompoundsfoundwithinthegrapefruit can interfere with an enzymethatbreaksdownmedicaMoninyourbody.If the enzyme cannot breakdownmedicaMon properly, it may build up todangerouslevelsintheblood.

SevilleorangesandpomelosarealsothoughttohaveasimilareffectandsoyoumayneedavoidtheseifonanMretroviralsorothertreatment.Alwaysmakesuretocheckwith your pharmacist to see if there are any food‐drug interacMons with anymedicaMonthatyoutake,includingthoseforothercondiMonsbesidesHIV.

MEDICATIONSMostoverthecountermedicaMonsaresafetotake,evenwithHIVmedicaMons. If there are specific drugs that interactwithany HIV medicaMons you may be taking, your pharmacistshoulddiscussthemwithyou,andifnot,don’tbeafraidtoask!SomemedicaMonsthataresoldwithoutaprescripMonthatyoumay want to check in with your pharmacist about includeanMhistamines(allergymedicaMon)andsomeantacids. Therearealotofdrugsthatwedon’tcurrentlyhaveanyinformaMonforandsoifyouexperienceanyunusualsymptomsamertakinga new medicaMon (prescripMon or over the counter) orsupplement,youshouldconsultwithyourdoctororpharmacistassoonaspossible.

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There is a misconcepMon thatbecause supplements are“natural” they must be safe.Whilethisistrueofmostvitaminsand minerals when taken inrecommended doses, it does notapplytoherbalproducts.

Many herbal products, whileeffecMve, can have drug‐likeeffects in the body and/or altervarious body funcMons. Thismeans that they can affect yourimmune system or interact withmedicaMons you may be taking.Youshouldalwaysconsultwitha

SUPPLEMENTS

health care professional orpharmacist knowledgeable aboutherbal therapy. Employees inhealth food stores may seemknowledgeable but are nottrained in pharmacology ormedicineandsomaybeunawareof potenMal interacMons orcontraindicaMons with varioushealth condiMons. You can alsofind a lot of informaMon onlinebut keep in mind that thereliability and accuracy ofinformaMon on the internet canbequitevariable!

St. John’s Wort is probably the most famous when it comes to herb‐druginteracMons.Thisherbisusedforthetreatmentofmildtomoderatedepression,buthasamajor interacMonwithmostmedicaMons, includingthoseused inthetreatmentofHIV.

Contrary to theeffects associatedwith grapefruit, St. John’sWort can increasetherateatwhichyourbodybreaksdowndrugs.Thismeansthatthedrugleavesyourbody faster than it is supposed toandmayhavedecreasedeffecMveness.WithHIVmedicaMons this can be especially concerning because itmeans thatthelevelofmedicaMoninyourbloodcandropbelowtheamountneededtokeepthevirusfromreplicaMng. Whenthishappensitcancausethevirustobecomeresistant to the drug and may mean that you have to switch to a differentregimen.

Garliccan interferewithHIVtreatmentaswell. Ithasamajor interacMonwithSaquinavir,andpotenMalinteracMonwithmostotherHIVmedicaMons.Thisdoesnot mean that you should not eat garlic, but rather be cauMous when takingmoreconcentratedgarlicextractsupplements.

St.John’sWort

Garlic

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Echinaceaisaplantthatismostcommonlyusedinthetreatmentofcoldsandflus.WhileitmayhavepotenMal interacMonswithsomeHIVmedicaMons,its use is not recommended for HIV+ individualsfor another reason. It sMmulates the immunesystembyacMvaMngCD4cells,whichmayseemtobeadesirableoutcome,but isnot recommendedfor those who have certain immune systemdisorders, including HIV/AIDS. It is thought thatincreasedCD4cellacMvaMonmayincreaseviral

Echinacea

replicaMon,specificallywheninfectedCD4cellsaresMmulated.

Studies have also shown that Echinacea increases producMon of a substancecalled tumor necrosis alpha (TNF‐alpha) by the immune system. TNF‐alpha isproducedforthepurposeofkillingoffunhealthycells inthebody,buthasalsobeenlinkedtofasterprogressionofHIVdisease.

Getyoursleep!Thisisoneofthosepiecesofadvicethateveryoneshouldheed,regardless of HIV status. Your body repairs itself and integrates all of theimportantinformaMonthatyouacquiredduringthedaywhileyousleep. WhilescienMsts sMll haven’t figured out why we sleep, they have been able todemonstratetheimportanceofsleepandhowsleepdeprivaMonaffectsus,bothphysicallyandmentally.Sleep loss has been shown to impair immune system funcMoning and reduceyour ability to fight off colds and flus. A study published in 2009 found thatmammalswho spentmoreMme sleeping hadhigher numbers of immune cellscirculaMng in the blood – someMmes asmuch as six Mmesmore in those thatsleptthelongest!Lackofsleepcanalsoaffectperformanceonavarietyoftasks,bothmentalandphysical.

Whatisanadequateamountofsleep?Astudythatvoluntarilyinfected153parMcipantswithacoldvirusfoundthatthosewhosleptlessthan7hoursanightwerealmostthreeMmesmorelikelytogetsickthanthosewhogotatleast8hoursofsleepnightly.

Sleep

LIFESTYLE

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Tipsforgoodsleepinclude:•  Sleepinadarkroom.Thisincludesshuengofftelevisions,computerscreens,

andanythingelseinyourroomthatcangeneratelight. Evenshortamountsof light exposure during the night can disrupt your sleep‐wake cycle byinhibiMngproducMonofmelatonin,ahormonethatisessenMalforsleeping.

•  TakeMmebeforebedtoletyourbody“quietdown”fromtheday. WeomenrunaroundcompleMngday‐to‐daytasksunMl it’sMmetogotosleep. GoingstraighttobedcanleaveourmindsreelingwithallofthethingswesMllneedtodo,orwithworriesthatwedon’thaveMmetoprocessduringtheday.TrytodealwiththeseafewhoursbeforebedandthenspendsomeMmerelaxing.

•  Roomtemperature. Ensurethatyourbedroomisacomfortabletemperatureforyoutosleepin. Aroomthatistoohotortoocoldwillbeuncomfortableandmaycauseyoutowakeduringthenight,disrupMngyoursleep.

•  Exercise.MakingexerciseanimportantpartofyourrouMnecangoalongwayinhelping you to sleepwell. It helps to reduceanxiety, improvemood, andmayhelppromoteamoreresqulsleep. TrynottoexercisetooclosetoyourbedMmethough,astheadrenalineproducedduringexercisemay leaveyoutooenergizedtofallasleepforafewhours!

•  Agoodmalress.Makesureyou’resleepingonamalressthatiscomfortableforyou. Whetherit’sonthefirmerorsomerside,themorecomfortableyouare,thebeleryou’llsleep!

•  Agoodmalress.Makesureyou’resleepingonamalressthatiscomfortableforyou. Whetherit’sonthefirmerorsomerside,themorecomfortableyouare,thebeleryou’llsleep!

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•  SMmulants. SMmulants found in caffeinated drinks like soda and coffee,compounds in tea, nicoMne in cigareles, and recreaMonal drugs such ascocaine,areallexamplesofsMmulantsthatcaninterferewithyoursleep. Ifyou have difficultly sleeping you may want to consider avoiding these oravoidingtheminthelaterhalfoftheday,whentheireffectsaremorelikelytolastintobedMme.

•  Regular sleep schedule. Going to bed andwakingup at approximately thesameMmeeveryday,includingweekends,canimproveyourqualityofsleep.Setanalarmifyouneedone.

•  MedicaMons and supplements that can aid in sleep are available. AlwaysconsultwithyourdoctororaregulatedhealthcareprofessionalbeforetakingtheseassomecanhaveaddicMveproperMesandshouldalwaysbetakenwithmedicaladvice.

RecreaEonalDrugs

ManypeoplewhoareHIV+conMnueto use drugs recreaMonally amerthey receive theirdiagnosis. Whileoccasional use hasn’t been shownto lead to fasterprogressionofHIVdisease, heavy substance use canhave a negaMve impact on yourimmunesystem.

It is possible for some recreaMonaldrugs and HIVmedicaMons to haveinteracMonswitheachother. ThisisparMcularly true of proteaseinhibitors, which can increase thelevel of some recreaMonal drugs inyourbloodandputyouatahigherrisk for overdose. If you take HIVmedicaMon, talk to your doctor sothat you can anMcipate anyinteracMons. A good doctor willlisten,not judgeyou, andoffer yousupport.

Besides the direct impact on yourimmune system and withmedicaMoninteracMons,youhavetoconsidersomeoftheother

potenMal issues related torecreaMonaldruguse.

Besides the direct impact on yourimmune system and withmedicaMoninteracMons,youhavetoconsider some of the otherpotenMal issues related torecreaMonaldruguse.Dependingonwhat you take, some drugs canmake you lose track of Mme,whichcan pose a problem if you do haveto take your HIV or othermedicaMon.

Try seenganalarmonyourphoneorwatchthatcanremindyouwhento takeyourmedicaMonshouldyoulosetrackofMme.

You must also consider that somedrugs will reduce your inhibiMonsand may make you more likely toparMcipateinunprotectedsex.

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This can put both you and yoursexual partner at risk fortransmiengandcontracMngvarioussexually transmiled infecMons,includingHIV.

If you are able to plan ahead for aday or night of hard recreaMonaldruguse,itcanhelpyoutobesaferandtakebelercareofyourhealth.

Eat before, stock up on cleansupplies,andplanforarestdaythenext day where you can eat goodfood, hydrate, and get plenty ofsleep.

VaccinaEons

WhetherornotyouchoosetogetimmunizedisapersonaldecisionbutwithHIVthere are some things that need to be taken into consideraMon. Your risk fordevelopingandhavingcomplicaMonsfrominfecMonssuchaspneumoniaisgreaterwithHIVandsoyoumaychoosetogetvaccinatednowifyouhaven’tpreviously.Geengaflu shot is also recommended forpeoplewhoareHIV+ andhas tobedoneyearlyforyoutostayprotectedsincetheflustrainschangefromseasontoseason.

TherearesomeimportantthingsforyoutobeawareofwithvaccinaMons.IfyourCD4countislow,avaccinemaynotworksinceyouneedtobeabletocreateanimmuneresponsetothevaccinetobecomeprotected. IfyouareabouttostartHIVtreatmentyoumaywanttowaitunMlyourCD4countincreasesbeforebeingimmunized.Speakwithyourdoctoraboutwhatthebeststrategyisforyou.

Avaccinecanalsocauseatemporaryincrease(or“blip”)inviralloadintheweeksameryoureceiveit. TheimmunesystemisacMvatedinresponsetothevaccine,which also means increased viral replicaMon, which can cause a blip in yournumbers. Trytoavoidhavingyourviralloadmeasuredforseveralweeksamer,orifyoumust,don’tpanicifyouseethatyourviralloadhasgoneup.

Finally, there are certain vaccines thatHIV+ individuals shouldnot receivewhiletheir CD4 count is low and so it is important that your health care provider beawareofyourstatus. Somevaccinescontain“live”butweakenedstrainsof thevirusorbacteriathattheyareintendedtoprotectagainstinordertogenerateanimmune response. In someonewhose immune system is compromised, it cancausesomeseriouscomplicaMonsandeventhediseasethevaccinewascreatedtoprevent.Examplesof“live”vaccinesincludechickenpox,smallpox,yellowfever,andtheMMR(measles,mumps,rubella)vaccine.

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The Toronto People With AIDS Foundation exists to promote the health and well-being of all people living

with HIV/AIDS by providing accessible, direct, and practical support services.

TORONTOPEOPLEWITHAIDSFOUNDATION200GerrardStreetEast,2ndFloorTelephone:416‐506‐1400Fax:416.506.1404Generalinquiries:info@pwatoronto.orgCharitableRegistraMon#:131113151RR0001

ACKNOWLEDGEMENTS

ThistreatmentbulleMnwaswrilenbyJenniferGrochocinski,ND,TreatmentResourcesCoordinatoratthe

TorontoPeopleWithAIDSFoundaMon(PWA).

PWAthanksErinAlphonsoforherMmeandcreaMvityindesigningandformaengthisbulleMn,andLaraBarkerandtheCanadianAIDSTreatmentInformaMonExchange(CATIE)forreviewingthecontenttoensureaccuracy.

PWAalsothanksBristol‐MyersSquibb,GileadSciences,Merck,andViiVHealthcareShireCanadaforsupporMngPWA’sTreatmentBulleMns.