HIV+ and on Meds - Greater Risk for Infections

[David_CA]

I just got back from an appointment with my ID Dr. He's also my primary care physician.  We got in a discussion about whether or not HIV+ people on meds with decent CD4 counts are at any more risk than HIV- people.  He said no, I say yes.  For one thing, we're not supposed to have live vaccines.  He also says we're no different than HIV- people when our T-cells are high.  I had to ask if that was his opinion, as others disagree.  Then there's that pesky thing called ADA which states that an HIV diagnosis is considered a disability.  What are others' opinions / thoughts / experiences with this?

[Billy B]

Hi David- I asked my ID the same question concerning the shingles vaccine. I have several friends, family and coworkers who are cancer survivors (all -) and they have all had shingles after their cancer treatments.  He advised me against getting the vaccine but I don't have great numbers like you.
After our discussion he told me that he had a couple outbreaks of shingles and he had the vaccine.
Peace,
Billy

[pozniceguy]

MY  ID  Dr  is also a researcher...does numbers of  studies in his  clinic all year long,   has  for  years...he says that your  position has substantial support among researchers......  HIV+  seem more  at  risk  for  other infections   ..   even people with good cd/ undect  status......  when he  runs a trial he is  very selective about  allowing  certain groups  to become part of  trials.   especially true  with treatment naive  persons  .He  does not  agree however that   HIV  is  of itself a "disability"     the  surrounding circumstances (  OIs, poor physical condition,other  issues ) usually make  many HIV+  persons eligible  for  Disability...  he is a believer in  doing whatever you can as naturally as possible without special consideration of HIV status....

Nick  

[David_CA]

It's funny you mention shingles; I had 'em back in the late spring / early summer.  My Dr. says they're common for people below 60.  I had to remind him that I'm not even close to 60.  I asked how many 45 year-olds he knew of that had 'em, and he couldn't really remember them.  As I recall, the shingle vaccine isn't supposed to be given to HIV+ individuals.  

[David_CA]

MY  ID  Dr  is also a researcher...does numbers of  studies in his  clinic all year long,   has  for  years...he says that your  position has substantial support among researchers......  HIV+  seem more  at  risk  for  other infections   ..   even people with good cd/ undect  status......  when he  runs a trial he is  very selective about  allowing  certain groups  to become part of  trials.   especially true  with treatment naive  persons  .He  does not  agree however that   HIV  is  of itself a "disability"     the  surrounding circumstances (  OIs, poor physical condition,other  issues ) usually make  many HIV+  persons eligible  for  Disability...  he is a believer in  doing whatever you can as naturally as possible without special consideration of HIV status....

Nick  

Nick,
Are his studies published?  I'd love to get information supporting your Dr's and my position.  Mine has dealt with HIV for decades, but I'm not sure how much of it has been research / studies.  I know that I have less energy / greater fatigue, have greater allergic response to insects and air-borne stuff (lots of stuffy nose and sinus issues), shingles, etc since becoming positive and can't get certain vaccines due to complications of HIV. 

[Billy B]

David- I knew that the Shingles Vaccine was not indicated for + people but I have read where some + people with high CD4 numbers had the vaccine without a problem. My sister had them at 43 but it was after the breast cancer and chemo nearly killed her. She said shingles was worse than the whole cancer treatment. Hers was located on her neck, face and side of her head and she still has pain from it after two years. 
Peace and I still love the pic,
Billy

[bocker3]

Note:  these are my opinions -- not facts, not based on research -- just based on what I've learned, experienced and a some "connecting the dots".

It would seem that, if HIV attacks CD4 cells and that their depletion is what leads to all sorts of infections, one would expect that one's immune system would return to near normal if your CD4s rebound to where they were prior.  Of course, almost no one has a pre-HIV CD4 baseline.

I suspect that much of the "positive folks shouldn't get vaccine X" is left over from before the days of effective treatment.

I have not, personally, noticed any more or less "infections" since going on treatment.  Of course, everyone's body is different and may react differently to things.  It may also appear that some get more colds, etc. because one may be a bit more vigilant about noting such things post-diagnosis.  Not saying anyone, in particular, is doing so -- just my thought.  I know that, prior to my diagnosis,  I never realized that every Sept. my allergies cause a sore throat that lasts for about a week.  Now, like clock work -- every Sept, my sore throat comes.

Mike

[skeebo1969]

I just got back from an appointment with my ID Dr. He's also my primary care physician.  We got in a discussion about whether or not HIV+ people on meds with decent CD4 counts are at any more risk than HIV- people.  He said no, I say yes.  For one thing, we're not supposed to have live vaccines.  He also says we're no different than HIV- people when our T-cells are high.  I had to ask if that was his opinion, as others disagree.  Then there's that pesky thing called ADA which states that an HIV diagnosis is considered a disability.  What are others' opinions / thoughts / experiences with this?

  A professor who taught one of the courses in the nursing program I was in back in Sebring said the same as your ID doc.  That those diagnosed today and who maintained high Cd4 counts were as healthy as negative people.  He was a retired oncologist who said he treated many of the early AIDS patients during the late 80's and early 90's.   My new ID doc told my wife this as well during our first appointment last week.  It's an interesting question, David.

  Does ADA treat it as a disability?  I was under the impression it offered protection against discrimination for those living with HIV/AIDS.  I'm not disputing what you're saying, just curious...

  T

[leatherman]

Does ADA treat it as a disability?  I was under the impression it offered protection against discrimination for those living with HIV/AIDS.

http://www.ada.gov/qahivaids_license.pdf

2.   Q:  Are people with HIV or AIDS protected by the ADA?

     A:  Yes.  An individual is considered to have a "disability"
if he or she has a physical or mental impairment that
substantially limits one or more major life activities, has a
record of such an impairment, or is regarded as having such an
impairment.  Persons with HIV disease, both symptomatic and
asymptomatic, have physical impairments that substantially limit
one or more major life activities and are, therefore, protected
by the law.

[skeebo1969]

  Thanks Mikey.

[spacebarsux]

I think it definitely helps my mental state thinking that as long as I have CD4s that fall within the normal range I'm as healthy as and no more prone to infections than an HIV-free individual .

Sadly, my experience indicates otherwise. Although I was diagnosed early this year, I've been infected since sometime in 2005 and in retrospect I know that I've had more bouts of an upset stomach and irritable bowels, sinusitis and skin issues in the last 5 years than before I was infected.

However, I haven't been on meds and someone who is on treatment and is  maintaining healthy CD4s is possibly considered as healthy as a negative person, at least I hope so. 

[David_CA]

I believe the 'HIV automatically being an ADA disability' comes from the protections that such a designation gives.  In other words, discrimination based on HIV status, etc are covered this way.  Also, the opinion that some of these doctors seem to have is like "yeah, yeah, so you're HIV+.  Pop a pill and you'll be fine."  Isn't the message that we fight to NOT send out?  Until HIV meds are as accessible as a general antibiotic, such as penicillin, and obtaining such meds is guaranteed, our health has the potential to deteriorate quickly. 

[buginme2]

I think it definitely helps my mental state thinking that as long as I have CD4s that fall within the normal range I'm as healthy as and no more prone to infections than an HIV-free individual .

Ya I don't agree with this.  Sorry to be such a Debbie Downer.

Maybe you won't get the big bad AIDS OI's like PCP and CMV and such.   I still feel your at greater risk of becoming sick with other OI's, skin conditions, heart disease, kidney disease, liver disease and the grandaddy of them all CANCER!!

I've read that lymphomas are quite common. 

And PS the disability thing has nothing to do with "health.". Its strictly a discrimination issue.

[Miss Philicia]

I still feel your at greater risk of becoming sick with other OI's, skin conditions, heart disease, kidney disease, liver disease and the grandaddy of them all CANCER!!

As a technical matter are those considered "infections"?

[buginme2]

I don't think so.  We will just consider them in the category of "honorable mention"

[Joe K]

The idea of whether we are similar to negative folks, health wise, is really a nonstarter for me.  How could you ever determine if it is true or not?  Given the difference in people, there are negative folks bordering on death from some disease, just like there are pozzies who are healthy as can be.  It feels like comparing apples to oranges, but I also wonder why does it matter?  I'll never know if I would be healthier if I was negative.  Sure I can make assumptions that I probably would be, simply because of the damage I have sustained from being poz.  Then again, I could be HIV free and still have some debilitating disease, because HIV is not the only danger that we mortals face.

I don't wonder about ideas such as if I am better/worse because of this or that, because it all results in mere conjecture.  There is no way to ever know how different my life might have been and personally I choose to spend my time making the most out of the life I DO have.

[Miss Philicia]

But this is why I'm confused with this thread -- the OP is about increased infection susceptibility as being irrelevant to cd4 count, yet most people are conflating issues with other stuff (i.e. kidney and liver disease, cancer).

I look at it this way: Is an HIV+ individual with (for the sake of argument) >1,000 cd4 more susceptible to (again for the sake of argument) respiratory infections than someone without HIV? I think clearly the answer would be "no".

[Buckmark]

David,

I think your doctor is oversimplifying things, probably for his convenience.  It's not clearly to me if the risk you are talking about is increased susceptibility to infection, which Miss P. refers to above, or more difficult treatment of infections.   I'd think the latter might be a little more complex in individuals with HIV.  Look at Phild's recent thread on syphillis ("Dayummm Syphilis").  I believe there was discussion there of how syphilis can be harder to treat in HIV+ individuals -- not sure if there are any studies or not.

Cheers,

Henry

[David_CA]

Let's expand a bit, since there seems to be some confusion.  The implication of my Dr. is that HIV+ individuals are no more likely to have health issues that are not related to or caused by meds.   Infections were used only as one of the examples, but I'd surely add things such as cancers and other issues.  Accuracy is not key here (such as strict definitions); what I wanted to discuss is the statement that the virus itself, although in low quantities in blood samples (this does not consider the 'reserves' in other places in the body) and potentially damaged T-cells from when many of us had lower CD4 counts.  Another thing I wonder about, which is somewhat related, is why some people have low CD4's despite being on meds / undetectable.

[Miss Philicia]

The implication of my Dr. is that HIV+ individuals are no more likely to have health issues that are not related to or caused by meds.   Infections were used only as one of the examples, but I'd surely add things such as cancers and other issues.  Accuracy is not key here (such as strict definitions); what I wanted to discuss is the statement that the virus itself, although in low quantities in blood samples (this does not consider the 'reserves' in other places in the body) and potentially damaged T-cells from when many of us had lower CD4 counts.  Another thing I wonder about, which is somewhat related, is why some people have low CD4's despite being on meds / undetectable.

Thanks for trying to clear that up. Clearly studies have showed pozzies are at increased risk for a variety of ailments (ailments being different than infections). That said, without being in the room with your doctor it's not clear to me exactly what he said verbatim. As you said, you were also specifically referencing pozzies with high cd4 counts versus those with lower counts -- even that's fuzzy without defining what counts as a high number.

So I look at it as this -- with my cd4 count being quite high, am I at higher risk for an odd infection when I have surgery. Answer: no

Am I at higher risk for heart problems than my HIV-negative brother? Yes. But even that would be a matter of degrees -- clearly I'm not at as high a risk if my brother was wildly obese with sky high lipid panel numbers (he's not obese, I'm just adding it in here).

[David_CA]

Henry,

Those are some of the exact thoughts I was wondering about.  I found it somewhat disconcerting that a highly rated ID doctor who's treated HIV for so long was so dismissive of HIV related issues.  I also thing that we're sometimes given canned answers and responses for conveniences.  Honestly, I don't think that most people would question their doctor as much as I or many of us would.  I know that when I was diagnosed with HIV, I was listed as a 'contact' from an individual diagnosed with syphilis.  The treatment for HIV+ people is not one set of shots; it's a series of three.  This was unrelated to T-cell level, viral load, etc.  As it turned out, I never had been infected with syphilis despite having been forced to have those extremely painful shots.

David,

I think your doctor is oversimplifying things, probably for his convenience.  It's not clearly to me if the risk you are talking about is increased susceptibility to infection, which Miss P. refers to above, or more difficult treatment of infections.   I'd think the latter might be a little more complex in individuals with HIV.  Look at Phild's recent thread on syphillis ("Dayummm Syphilis").  I believe there was discussion there of how syphilis can be harder to treat in HIV+ individuals -- not sure if there are any studies or not.

Cheers,

Henry

[skeebo1969]

The idea of whether we are similar to negative folks, health wise, is really a nonstarter for me.  How could you ever determine if it is true or not?  Given the difference in people, there are negative folks bordering on death from some disease, just like there are pozzies who are healthy as can be.  It feels like comparing apples to oranges, but I also wonder why does it matter?  I'll never know if I would be healthier if I was negative.  Sure I can make assumptions that I probably would be, simply because of the damage I have sustained from being poz.  Then again, I could be HIV free and still have some debilitating disease, because HIV is not the only danger that we mortals face.

I don't wonder about ideas such as if I am better/worse because of this or that, because it all results in mere conjecture.  There is no way to ever know how different my life might have been and personally I choose to spend my time making the most out of the life I DO have.

I totally agree with this line of thinking, well said Joe.

To be honest, I do believe I am more healthier now than I've ever been during my adult life.  Specifically, my 21-25 year old range...  

Maybe you won't get the big bad AIDS OI's like PCP and CMV and such.  

I have been diagnosed with CMV

And, CMV is not necessarily an OI per say.  It's actually a virus a large part of the general population has.  It only becomes an issue in those with  a severely compromised immune system.  It's in these people where it can become deadly, or at the very least cause blindness--  CMV retinitis.(OI)

If your Cd4's stay below 200 for a period of time, and you've been diagnosed with CMV, you'll definitely want to keep that yearly eye exam we're all supposed to have anyways.  

[odyssey]

My doctor says my "immune system is intact." He explained that to my psychologist to mean there's no reason to believe I'm going to get sick. Just adding my experience.

[David_CA]

One thing I think that some forget is that some of what's happened to us because of HIV / AIDS lives on even after meds. For example, my lung capacity still sucks after PCP... and it's been almost 5 years. I know that's not an infection or illness, but it still causes problems. I was recently diagnosed with pre-COPD, or COPD Lite as I call it. Perhaps I've always had this, but it wasn't noticible until after the lung damage.  Maybe it and the PCP together are what causes me breathing issues.

[eric48]

As you age, then come a number of confounding factors.

I had been (mis)diagnosed for leg nerve neuropathy and the HIV-specialized neurologist I went to said that glucose resistance and insulin resistance (2 things leading to diabetes 2 down the road) make more damages to nerves than HIV (for a 'modern-day' Hiver, I assume)

Besides, the immune system is not only about CD4 count, but also about Lymphocytes balance and diversity

Cheers !

Eric

[bufguy]

I asked a very similar question a few years ago at the body.com. Here is the response:

  risk of infections
Aug 26, 2008

When I first tested positive, my doc had me vaccinated for hep a & B, pneumonia, tetanus. Obviously to help protect what could be eventually a compromised immune system.My initial Vl was 47,500, CD4 511/29%. After 5 weeks on atripla, my Vl is 130, CD4 667/31%. Good numbers I believe. If I'm able to maintain these good numbers am I any more succeptible to infection than an HIV- person or is there something about being HIV+ regardless of good numbers that make infection all the more likely? Put another way, if there are two people, one +, the other -, both with exactly the same CD4 numbers, is the + person more succeptable to infection?

 
 
 
  Response from Dr. Henry
HIV+ persons with decent CD4 counts (> 350-500) have much the same risk and outcomes for community acquired infections as HIV- persons with some exceptions. There is an increased risk for infections due to Strep pneumonia, herpes zoster, TB and possibly methicillin resistance staph infections and some others. Other infections can pose additional challenges to treat (as compared to HIV- populations) such as hepatitis B or C or human papilloma virus infections. Overall it is remarkable how well HIV+ persons doing well on treatment compare to HIV- matched persons. KH
 

[mecch]

Several specialists in different medicines have said that my lifestyle choices are far far more determinant of my current health, health risks, and longevity than me being HIV+ and on successful treatment.

[elf]

As for vaccines, my doctor is recommending yellow fever vaccines to all HIV+ people with CD4>500 who travel to endemic regions. Around 30 patients of his (who work as professional sea men) have had the yellow fever vaccine, and no side effects at all.
It takes longer for antibodies to appear in blood, and that's all.

[elf]

I've read that lymphomas are quite common.  

You don't need to have HIV to get a brain cancer or a lymphoma.
Andy Whitfield (from Spartacus) died earlier this year at the age of 39, and he was fit and HIV-.

Reynaldo Gianecchini has been diagnosed with a rare lymphoma, recently. I don't think he is HIV+.
http://www.homotrophy.com/celebrity/reynaldo-gianecchini-paparazzo/


http://www.aidsbeacon.com/news/2009/10/16/study-suggests-higher-cd4-counts-reduce-risk-of-hiv-induced-cancer/

I have a bad case of rhynitis as we speak, but it's my fault. There's been a sudden temperature change (form 77F 25 C to 41F 5C) in only three days, and only today I got into fall/winter clothes. I should have taken better care of myself.
  Temperature change, putting the heating on, but still in shorts, and there you go, runny nose.

[buginme2]

You don't need to have HIV to get a brain cancer or a lymphoma.

Of course not.  I never meant to imply that you can only get lymphoma if you have HIV.  All I meant to say was that having HIV is a risk factor for developing cancers such as lymphoma.  

Source: mayo clinic
Certain viral and bacterial infections appear to increase the risk of non-Hodgkin's lymphoma. Viruses linked to increased non-Hodgkin's lymphoma risk include HIV, hepatitis C virus and Epstein-Barr virus

http://www.mayoclinic.com/health/non-hodgkins-lymphoma/DS00350/DSECTION=risk-factors

Edited to add:  Many people who are HIV+ are also co infected with Hep c and Epstein-Barr

[eric48]

for those interested there is a very detailed, layman friendly presentation here:

http://www.cancer.gov/cancertopics/understandingcancer/immunesystem

scowling through slides is quite easy until slide 19, then for some underlying code reason, it takes a little bit more scowl down effort to navigate to 20 and so forth

Slide 32: Immunity and Cancer

is where the relationship between immune system and cancer gets explained (needless to say the 30+ previous slides are very informative to learn about the immune system in general)

unfortunately the relationship between cancers and immune system is not fully understood (cancers and immune systems , are not fully well understood even considered individually...)

But some cancers establish a steady state balance where the immune system keeps the emerging cancerous clusters (buds) in check until, generation after generation, the cancerous cells mutate and find a way to escape. Some cancers are immuno-dependant (some are not...) (BTW some are hormone dependant)

Since some people have an immune system damaged in such a way that the restoration is either incomplete or partially complete (in all its various segments, which far exceed the sole CD4 cell segment) at the time cancerous cells are challenging the immune system, then it makes it easier for the cancerous cells to escape the immune system

The interesting finding about the elevated incidence of some cancers in HIVers is that it highlights that some cancers that have a stronger interaction with the immune system than previously identified.

Restoring the immune system to its 'normal' anti-OI state may only take a few months (as measured by CD4 counts)

Restoring the immune system to its 'normal' anti-cancer capabilities may only take much longer

which is why, IMHO, the older patient (like myself) should start therapy earlier (or at higher threshold) than usually recommended in guidelines that consider only CD4 counts and do not include the age of the patient (hence his/her susceptibility to cancers and his/her time to full recovery) as a deciding factor.

Hope this helps

Eric