Sometime back I got into the habit of saying to myself “well it’s chemotherapy, stupid”! This would usually occur at about 5 am when 1 had crawled out of bed to pee and take my four ddl tablets. Choking those suckers down first thing in the morning was always a particularly unpleasant way to begin the day. 1 do think deli is a beneficial antiviral, perhaps actually under used even. However, I was frequently rilled with righteous indignation at having to do it at all and wondered why this AIDS treatment business couldn’t be just a bit more pleasant. Being very aware of course that the “full-blown out of control version” has a tendency to ruin every day!!

I have myself recently crawled to the “Altar of Protease” and bowed deeply and am once again reminding myself that “it’s chemotherapy, stupid”, it ain’t supposed to be fun Despite the ads appearing particularly in the gay press, advertising various antivirals accompanied by photos of half naked hot studs engaging in some vigorous outdoor activity displaying buns of steel, they are very difficult drugs to take with significant side effects. They are chemicals, that don’t routinely pop up in our food for example, being used as therapy, i.e. chemotherapy. Before I go on let me throw a shot at the drug companies., one of my favorite activities, for promoting these drugs through ads with sexy models. Hey buckos, it was/is the glorification of that sort of shallow flesh worship that got many of us in this pickle in the first place, The irony is not appreciated, I can hear my critics now saying, “that old queen is just bitter because he’s lost his ass”!

I fully acknowledge the enormous benefit of the various combination therapies and see daily many folks pulled back from the brink of death to lives better than they have experienced in many years. If your HIV has begun to cause any problems you need to get started as soon as possible and unfortunately many of the early sorts of problems can be subtle and easily blown off.

However, there are a couple of emerging issues that we need to look at with a critical eye and one of those is just when to begin these therapies. 1 have for sometime disagreed with the proponents of hard aggressive therapy for anyone HIV positive and become more certain of my cautious approach with each passing day. Resolute (June/July issue) recently ran a thoughtful piece on when to start therapy done by Project Inform out of San Francisco and though I felt it to be just a bit timid and out of touch with the reality of the street a very worthwhile dialogue nonetheless, if T-cells are fairly high (400+ ?) and viral load low (under 25,000 ??) and you have no clinical symptoms, and foe very honest here with your care provider about symptoms, sit still and follow things closely. To my health care provider peers I would encourage everyone to be meticulous with history taking and physical exam, and not simply reach compulsively for the prescription pad. Oral health in particular can be a real sentinel of good health or looming problems.

One of the big unanswered questions is whether or not particular types of T-cells with particular immune responsibilities are being selectively depleted even while overall counts are maintaining and no discernable HTV related physical findings are evident, therefore making an argument for early treatment. I do not have a clue. I do know though that thousands have rebounded with only modest increases in T-cells and the major AIDS related opportunistic infections have dramatically decreased.. Something starts working pretty well here again in folks who have had plenty of time to trash lots of T-cell lines! Also as time goes by the very real side-effects of taking these drugs for long periods of time becomes more evident and I think warrants a cautionary approach to beginning therapy.

Now a bit about these side-effects and the first one Hi address is the psychic impact of taking them every fucking day. If you ain’t walked the walk then you should talk the talk with caution. For those who may have crawled to the edge and experienced the drag of “full blown” AIDS hell taking these medicines when they make you feel so much better is relatively easy. For folks who have never been ill it is a whole different story, I find myself now providing encouragement to keep it up even to those who have received dramatic benefit. Many seem to reach an ironic point where the HiV related stuff gets under control and the drug side-effects begin to enter one’s consciousness as primary. It is only .human nature to forget yesterday’s hell and get easily annoyed with today’s purgatory. Sorry, I was raised Catholic!

One scary emerging side-effect are the changes that seem to be occurring for many people in their fat metabolism, elevated levels of triglycerides and cholesterol along with unusual fat depositions i.e..the now infamous “buffalo hump”. 1 am not ready to totally lay the blame at the feet of the protease inhibitors, the reverse transcriptase inhibitors may also be culprits here and if not they do have their own set of long term potential problems. Remember these drugs were not felt to-be very effective early on and were frequently not taken with the same diligence they are today. Its ail chemotherapy, and we are being asked to do it indefinitely. 1 always felt that what killed many people with AIDS was starvation brought on by a complex constellation of factors. “Fat is our friend” became a mantra. Well that seems more and more today to be bad advice.

This seems very unfair and I empathize deeply with the pained expression I recently saw on someone’s face when 1 told him his fasting triglyceride level was 1400+ and daily trips to McDonald’s may not be the best idea. I am seeking some clarification from drug companies on whether or not taking their drug with food to enhance absorption means taking it with fat. The answer will probably be that those studies have not been done. Fortavase is recommended within two hours of a “full meal” whatever that may include certainly some fat, but the F-word is not specifically mentioned. Norvir is recommended with meals if possible, with data to indicate that absorption is definitely better in the non-fasting state. Viracept is also recommended with food. Again it is not specifically recommended that you take it with fat foods though the diets tested with drug administration did contain significant fat. Will protein and/or carbohydrates work as well? Are we just trying to slow transit time and therefore increase absorption? How about a glass of skim milk? And of course remember that when all one does is lay around all day like a slug watching the soaps and Judge Judy, the body can turn nearly anything into fat. Move it!! Are we looking down the barrel of HIV-weight watchers here?

In addition to being conscious of our diet I am strongly encouraging aerobic exercise, something that may help counter the effects of less than optimal dietary habits . Also- it seems like very good advice these days to take a muitivitimin daily, a cheap generic variety works if money is an issue.

These are emerging areas we need to be aggressively addressing as a community concerned about our long term well-being. Let me reiterate again m this piece that the AIDS activist community has gotten us where we are today by assertively participating in our care and therapies. Now is not the time to lay back passively and swallow. Demand to know as much as possible about what it is you are being asked to swallow and what might be the short and long term side-effects. Where are those uppity folks with lesions on their faces and pearls around their necks questioning and challenging every word of the gospel according to the AIDS establishment?

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