Positive Living Winter 2013 by NAPWHA

PositiveLiving A MAGAZINE FOR PEOPLE LIVING WITH HIV l WINTER 2013

A place to call my own PLUSu BEATING THE WINTER WILLIES

PositiveLiving ISSn 1033-1788

eDITOR Adrian Ogier (adrian@napwha.org.au) ASSOcIATe eDITOR David Menadue gueST eDITORS fOR THIS ISSue

Stevie Bee and Vicky fisher cOnTRIBuTORS Jae condon, Petrea king, James May, neil MckellarStewart, Muktakiran, Dr louise Owen, Jo Watson, Peter Watts DeSIgn Stevie Bee Design Positive Living is a publication of the national Association of People With HIV Australia.

Positive Living is published four times a year. next edition: September 2013 Positive Living is distributed with assistance from

SUBSCRIPTIONS free subscriptions are available to HIV positive people living in Australia who prefer to receive Positive Living by mail. To subscribe, visit our website or call 1800 259 666. contributions are welcome. In some cases, payment may be available for material we use. contact the editor. ADDReSS cORReSPOnDence TO:

Positive living PO Box 917 newtown nSW 2042 Tel: (02) 8568 0300 fReecAll: 1800 259 666 fAx: (02) 9565 4860 eMAIl: pl@napwha.org.au WeB: napwha.org.au n Positive Living is a magazine for all people living with HIV in Australia. contributions are welcomed, but inclusion is subject to editorial discretion and is not automatic. The deadline is 21 days before publication date. Receipt of manuscripts, letters, photographs or other materials will be understood to be permission to publish, unless the contrary is clearly indicated. n Material in Positive Living does not necessarily reflect the opinion of nAPWHA except where specifically indicated. Any reference in this publication to any person, corporation or group should not be taken to imply anything about the actual conduct, health status or personality of that person, corporation or group. All material in Positive Living is copyright and may not be reproduced in any form without the prior permission of the publishers. n The content of Positive Living is not intended as a substitute for professional advice. cOVeR IMAge kWAnISIk

Dear Positive Living I’d like to give feedback on a recent article about dental care in your magazine. I was taken aback with the comments that now that the Chronic Disease Dental Scheme has been revoked, somehow an HIV+ person can afford private health insurance to pay for a private dentist. Firstly, a positive person on DSP could never afford the extortionate cost of private health insurance for dental cover. Even if you get one of the best plans there are still sublimits to how much you can claim, leaving you potentially hundreds of dollars out of pocket for treatment, on top of the premium you’ve just paid. Secondly, the public dental system is atrocious. With waiting periods of years for non-urgent dental care, it leaves you either ignoring your dental care until you have an issue serious enough to require extraction or you try to fork out money to pay for a private dentist just to get a checkup. Then what happens if the dentist finds a problem while they are cleaning your teeth? Well, you’re screwed. So, as opposed to your organisation lobbying the federal government to bring back the scheme for positive people, who desperately need to maintain good oral hygiene (in fact, it is

Teeth-grinding news item scientifically and medically proven that bad oral health can lead to further complications, such as immune issues and even heart disease), you simply write an article about how you should ‘support’ the private dentist you were using by getting private health insurance, or simply wait in the public system. Richard Olsen Positive Living replies Together with the Consumer’s Health Forum, ACOSS and other chronic illness groups, NAPWHA lobbied long and hard for the Chronic Disease Dental Scheme (CDDS) to continue. And it did last years longer than anyone imagined it would — something we reported in this magazine along with constant reminders to make good use of it. We supported dentists to advocate with government and before it was finally pulled late last year, we petitioned ministers and even

Mailbox went on ABC National at the eleventh hour to explain how vital it was for PLHIV. But opposition to it had always been strong and it won out in the end. The news item did not tell this story. Its focus was on the importance of PLHIV maintaining their dental care and how to access services in the current climate — which, we agree, is far from ideal. But there is hope. For those who can afford it, health insurance was flagged because it can significantly lessen the financial blow of any substantial work that needs doing. Having it can also prompt you to schedule regular dental visits. For those on lower incomes — where the public system is the only option — things are improving. The ‘better access’ that Health Minister Tanya Plibersek

promised us when she closed the CDDS appears to be progressing. In April, she opened a vastly upgraded Centre for Oral Health at Nepean Hospital in Sydney’s west — increasing the number of dental chairs there from nine to 32. This is all part of the government’s $4.6 billion promise to boost access to public dental health for regional and remote Australians. Another component of this deal is to channel more dental graduates into the public system — 46 this year, building to an extra 100 a year by 2016. Go to health.gov.au/internet/ ministers/publishing.nsf/ Content/mr-yr13-tp-tp002.htm for a list of public dental services that are flagged to receive a boost under this scheme. The Chronic Disease Dental Scheme was a godsend. But if we wait for it to return, many of us will revert to the gap-toothed, gum-diseased state we were in before it came along. To maintain our dental health, we must continue to access services the best way we can. Meanwhile, NAPWHA will continue to lobby for a better dental deal for all PLHIV, along with the other work we do to make treatments and healthcare more affordable and accessible. Adrian Ogier, editor

readers’ survey: you like us this much! Thank you to everyone who completed the survey in our last issue. We’re particularly grateful to those of you who took the time to provide us with personal comments and suggestions. According to your responses, the majority — but by no means all of you — are HIV positive (84.6%), male (88.5%) and gay (77.3%). Most of you are older (81.9% are over 40) and have been reading us for quite a few years (34.2% for more than 10). Almost all of you prefer us in hard copy, which you either get personally mailed to you (arrange

your free personal subscription by phoning us on 1800 259 666), collect from an HIV service or pick up along with your copy of the Star Observer (PL usually comes out in the Star Observer in the first week of March, June, September and December). All of you think we’re easy to read and understand and more than half of you read us cover to cover — mostly for information on HIV treatments (87.8%), health advice (70.3%), personal stories (67.6%), the news (55.4%) and the latest cure research (54.1%). The most popular columns are

CONTRIBUTORS (fROM lefT)

‘What’s your problem?’ (44.6%) and ‘State of mind’ (40.5%); and, by a landslide, most of you come away feeling ‘informed’ (94.4%). Over a third of you share your copy of Positive Living with someone else and a lot of you have recommended us to someone you know who is also living with HIV (63%). All in all, with a little tweaking, it looks like we’re pretty much on track. Remember, you can always feed us your thoughts directly to pl@napwha.org.au.

“I am glad it has kept going for so many years. The consumer voice is vital to ensure PLHIV get the best out of the health and other systems.” “Just want to thank you for such an informative newsletter. I have brain damage due to my virus and drug use and you keep it so easy to read and understand. Thank you; greatly appreciated.” “I look forward to it each quarter. Would like a couple of more 'superfood’ recipes, please.” We hear you and hope you enjoy the salmon and ginger broth.

Petrea King guides us through a meditation technique we can incorporate into our daily life l James May survives some less than perfect living arrangements l Neil McKellar-Stewart discovers how close we really are to finding the cure l Muktakiran offers some sage advice to those desperate for a good night’s sleep l Dr Louise Owen explores the possible causes of a relentless sore throat l Jo Watson whips up another superfood storm l Peter Watts shows us how to survive winter without getting the willies

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Something to say? Write to us pl@napwha.org.au

THENEWS IMD OuTBReAk

New York jabs

Lyrica approved for neuropathy Lyrica (pregabalin) has been approved by the Pharmaceutical Benefits Scheme (PBS) for the treatment of chronic nerve pain, including HIV-related peripheral neuropathy. Peripheral neuropathy (PN) is a form of nerve damage usually felt as numbness, tingling, burning or pain in the toes and feet, and sometimes in the fingers and hands. PN can be caused by HIV itself, especially at low CD4 and high viral loads, although symptoms may occur at any time. PN can also be a complication of diabetes, regardless of HIV status. Living with HIV and diabetes can increase the chances of developing PN. Remember to like us at facebook. com/positiveliving mag and receive all the latest HIV news from Australia and abroad.

Inquiry recommends medical use of cannabis NAPWHA has welcomed the unanimous recommendation from a NSW Legislative Council Select Committee to allow medical use of cannabis for people with a terminal illness, including advanced HIV disease. ‘Hopefully medical cannabis will be recognised as a preferred alternative to other forms of pain relief for people who are dealing with many symptoms related to their chronic conditions,’ said nAPWHA’s President Robert Mitchell. In their submissions, other sector organisations, including Positive life nSW, AfAO and AcOn, all supported a move to decriminalise cannabis use for personal medical use. The nSW government is due to respond to the committee’s recommendations later this year.

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There has been an outbreak of invasive meningococcal disease (IMD) among gay and other MSM in New York City and Brooklyn. A total of 22 cases have been reported over the past few years. The current recommendations are that all gay and MSM travelling to New York City or Brooklyn should be offered a meningococcal C conjugate vaccine (MenCCV) irrespective of their HIV status. HIV negative men require one vaccine dose only. HIV positive men require two vaccine doses given eight weeks apart. A booster vaccination is also recommended for those who have been vaccinated within the past five to ten years. Talk to your doctor or HIV clinic.

Two new hep c treatments get the go ahead

nSW uPPeR HOuSe cOMMITTee

New anal condom being tested A new condom designed exclusively for anal intercourse is currently being tested. Pending large-scale clinical trials and FDA approval, it is expected to hit the market in early 2015. The bonus of the anal condom is that it can be worn internally. This means that the receptive partner can now take the initiative and it eliminates the need for the insertive partner to wear a condom. The Origami anal condom is made of silicone and does not need to be unrolled. A simple insertion method anchors the condom and its internal lubrication and shape apparently help make anal sex a safe and pleasurable experience for both

partners. Also included in the Origami range are newly designed male and female condoms. Unlike the conventional rolled latex condom, the male version

functions much like a concertina. It provides a reciprocating motion of the penis inside the internally lubricated condom, something not possible with rolled latex condoms.

Two new therapies have recently been approved in Australia. Protease inhibitors boceprevir (Victrelis) and telaprevir (Incivo) are now available on the PBS to treat chronic genotype 1 hepatitis C (HCV). Professor Greg Dore, Head of the Viral Hepatitis Clinical Research Program at the Kirby Institute, says that these initial HCV direct-acting antiviral agents provide the first advance in HCV treatment for a decade. ‘Although associated with additional side effects,’ he says, ‘these therapies when combined with pegylated interferon and ribavirin improve cure rates and often shorten treatment duration.’ Professor Dore believes they are heralding a future where we will see direct-acting antiviral agents that promise to be even more effective and better tolerated. ‘There is the real prospect of interferon-free therapy in the next two to three years,’ he says. Today, around 13% of PLHIV are also living with hepatitis C. The virus is one of the most commonly reported notifiable diseases in Australia. It was estimated in 2011 that more than 300,000 Australians had been exposed to the hepatitis C virus and at least 220,000 were living with chronic hepatitis C. There is currently no vaccine to prevent hepatitis C and while some people can clear the virus naturally, these new medications provide a major step forward in curing the disease.

Have you been vaccinated against hep A, B? Hepatitis A is transmitted via the faecal-oral route — through the ingestion of contaminated food or water or from direct contact with an infectious person. The virus can survive for several hours on hands and considerably longer on food left out at room temperature. The infection can be quite nasty, but it doesn’t become chronic like

hepatitis B and usually goes away by itself. Vaccination against hepatitis A is often combined with the vaccination against hepatitis B, but you need to have a blood test afterwards to check whether it has worked. Hepatitis B is transmitted when contaminated blood, mucosa, semen or vaginal fluids get into your bloodstream. This

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can happen during unprotected sex or while sharing injecting or other skin penetration equipment. Symptoms can take months to appear. Most people clear the virus but some will develop chronic hepatitis B, which requires treatment. Hepatitis B vaccination involves a series of three injections given at 0, 1 and

6 months. It is really important to have all three vaccinations and then a blood test to confirm that you are immune. Even if you have had the full series of vaccinations for hepatitis A and B, your level of immunity may have dropped, so talk to your doctor about having a blood test to check your immunity and ask if you need a booster.

THENEWS An hIV cure has been mooted for some time. Neil McKellar-Stewart looks realistically at why we need one and the form it might take.

WHAT MIGHT A CURE LOOK LIKE? A cure might take two forms: the elimination of all HIV-infected cells within the body (a sterilising cure); or, alternatively, the generation of effective immunity to HIV, resulting in lifelong control of HIV in the absence of antiretroviral treatments (a functional cure, in which HIV is controlled by normal physiological processes rather than just suppressed by drug treatments). A functional cure also requires three other factors: effective immune function restored and stabilised;

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a massive decrease in HIV-induced inflammatory processes; and risk of HIV transmission reduced to zero.

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hese days, most PLHIV are able to achieve an undetectable viral load within three months of starting treatment and to sustain that level indefinitely. The benefits that modern antiretroviral (ARV) treatment provides, including reducing infectivity and strengthening your immune response, are well known. However, a strengthened immune response does not automatically mean a normal one. Even when immune system markers are restored to the normal range (800-1500 CD4 cells per mm³ of blood), these CD4s, CD8 T-lymphocytes and B cells — key elements of an effective response to infection — may still produce an inadequate immunological response. Modern HIV treatment is highly effective and life-changing, but it suppresses rather than eradicates HIV and it is therefore necessary to keep taking it for life. The effects of stopping treatment are very clear: viral replication, viral load and HIV-associated inflammation will all increase, often within weeks, as will the risk of developing cardiovascular, kidney and liver disease. Add to this lifelong need a constant rise in numbers of PLHIV, and we have a growing global therapeutic and health service funding challenge. The case for a cure is obvious and pressing.

The Cure

Are we any Closer? PositiveLiving l 4 l WInTeR 2013

SOME OF THE COMPLEXITIES: RESERVOIRS AND LATENCY Within a few days of initial infection, HIV is established in reservoirs within the body. These are sites or cell types in which HIV persists. Such cells contain HIV, which has been integrated into their DNA and in which normal replication processes generating new HIV viral particles have been blocked or ‘silenced’. Such cells are said to be latently infected or resting: they contain pro-viral DNA. These T-cells are relatively long-lived — in some cases years — and are part of the pool of memory cells that provide protection from bacteria and viruses with which we are threatened throughout our lifetime. ARVs interrupt the replication cycle of HIV at a number of points, depending on their class — for example, nucleoside reverse transcriptase inhibitors, integrase inhibitors, protease inhibitors and so on. However, they are only effective in T-cells that are active (not resting), and in which HIV is actively replicating. ARVs do not affect cells that are latently infected with HIV and in which active viral transcription has been silenced. Effective early treatment results in decreased total amounts of HIV RNA and reduced numbers of cells in which HIV has been integrated into the host DNA. There are fewer infected cells and a reduced reservoir of HIV-infected cells. But even with very early, intensive treatment, once infection is established, reservoirs soon develop. HIV may be present in a range of reservoirs: in CD4 T-cells in the gut and lymph nodes; in blood in long-lived memory T-cells; in a range of other cell types, including naïve CD4 cells not yet active in the immune system; and in specialised cells in the central nervous system. A cure for HIV will require that cells containing pro-viral DNA are either eradicated entirely from reservoirs (perhaps not achievable) or at least reduced so much so that the immune system is able to deal with them. Purging these reservoirs will require the latent provirus DNA in infected cells to be stimulated (switched on). Such cells when stimulated will either die from the destructive effects of the virus or be cleared by host immune defence mechanisms. At least three approaches have been proposed to purge HIV out of latency:

Stimulate the main host transcription agent, which facilitates HIV replication. That is, activate resting T-cells as a whole. Several drug and other agents have been suggested, some of these, such as interleukin-2 (IL-2), have been unsuccessfully trialled. This approach is risky, with possible unintended consequences. Generalised CD4 T-cell activation carries a major risk of

THENEWS generating a cascade of inflammatory molecules that may be harmful to a range of organs and may make the patient very ill.

Inhibit the action of complexes, including histone deacetylase, which block HIV DNA transcription. Several agents have been proposed, including valproic acid (trials have been unsuccessful); vorinostat (currently being trialled); and newer more potent agents: romidepsin, panobinostat, givinostat and belinostat.

Use a combination of these two approaches, stimulating transcription and inhibiting the compounds blocking it. Additionally, a range of molecules on the surface of both CD4 and CD8 memory cells may limit their ability to activate effective immune responses so that HIV-infected CD4 cells are recognised and killed. A cure will probably require addressing the role of such molecules.

BUT THERE’S MORE: DEALING WITH RESIDUAL VIRAL REPLICATION Once HIV has been purged from its reservoirs, the problem of lowlevel residual viral replication must also be dealt with. HIV infection causes ongoing inflammation and activation of the immune system, in particular in lymph tissues, where any residual HIV may continue to infect activated T-cells. Such inflammation must be controlled and immune responses enhanced, perhaps through a therapeutic vaccine. All this suggests that a cure will involve resolving numerous issues, some of which are poorly understood. THREE EXAMPLES OF WHAT A FUNCTIONAL CURE MAY LOOK LIKE

THE BERLIN PATIENT, a 40year-old HIV positive man who was responding well to antiretroviral therapy, developed leukaemia and needed a bone marrow transplant. He was successfully transplanted with a bone marrow containing T-cell surface receptors to which HIV was not able to attach. His HAART was discontinued at the

time of the transplant and now, up to six years later, detectable HIV RNA has not re-emerged. As well as the reconstitution of his immune system with cells not able to be infected with HIV, there are other factors that may have contributed to this apparent cure. They include the possible reduced size of the HIV reservoir caused by treatments preparing for his transplant and the use of immune-based therapeutics afterwards, which may have prevented low-level HIV replication and subsequent virological rebound. This is a unique case using costly and lifethreatening techniques, which are not feasible to apply generally.

At CROI 2013, there was the case of a PREMATURE BABY who tested positive to HIV RNA and DNA in two separate blood samples within a day of birth. (The mother was diagnosed with HIV infection at the same time.) The baby commenced normal therapeutic HIV treatment within 30 hours after birth. HIV was detectable on days 7, 12 and 20 but thereafter became undetectable for 18 months, presumably in response to effective HAART. At this point, the infant was lost to regular care (and thus treatments). The child re-presented and at 24 months, in the absence of treatment for six months, still had an undetectable VL. A single copy of HIV RNA in plasma was detected. Replication-competent virus was undetectable in resting CD4 Tcells, and finally at 30 months, after receiving no treatment for 12 months, HIV RNA and DNA, together with HIV-specific antibodies, all remained undetectable. If this child continues to live with seemingly controlled (and undetectable) HIV, this will probably constitute a case of a functional cure.

The third example involves 14 patients in the VISCONTI COHORT (Viro-Immunological Sustained CONtrol after Treatment Interruption). This cohort consisted of PLHIV from three separate French studies. It included 14 patients who were diagnosed very early and who commenced HAART within two months of infection. These 14 participants took an average of

three months to achieve undetectable VL. They all remained on treatment on average for 36.5 months, during which time their median CD4 counts rose 400 cells/mm³ to an average 930. They then interrupted their treatments —

cohort look like the very small percentage of people with HIV who are able to naturally control their HIV infection over many years. However, they differ from such ‘elite controllers’ in several significant ways. They have genetic immune markers, which

News from CROI 2013 At the recent conference on Retroviruses and Opportunistic Infections (cROI) held in Atlanta in March, the session Is There Hope for HIV Eradication? covered some issues related to the discussions above. The data on the functional cure in the premature baby was presented and generated much media attention. The other nine presentations provided information on a further range of issues. A team of researchers based predominantly in Australia reported on 20 people on long-term HAART with undetectable Vl for medians of five years and with cD4 counts of 721 cells/µl1. These participants received 400mg vorinostat once daily for 14 days and their blood plasma and rectal tissues were analysed to determine any changes in cell-associated HIV RnA and HIV DnA. Vorinostat, a histone deacetylase inhibitor, is postulated to purge HIV from reservoirs. The study demonstrated that short-term use of vorinostat was safe and that it increased the sustained expression of HIV by cD4 T-cells in blood and rectal tissue. unfortunately, it failed to demonstrate any significant change in HIV DnA from these potential reservoirs. In short, vorinostat did not actually shrink the size of the reservoir, and the study authors suggested that further strategies will be needed to eliminate latently infected cells. Another paper2 reported on 47 people who began treatment very early, within 25 days of infection. These people had their total integrated HIV DnA measured in blood and lower gut tissues at the commencement of treatment and after 24 weeks of treatment. In all participants, levels of integrated HIV DnA decreased dramatically. Seventy-two percent of those who began treatment within 25 days achieved undetectable HIV DnA in long-lived memory cD4 T-cells. This study showed that very early treatment restricts the seeding of the HIV reservoir, predominantly in cD4 memory T-cells. Other cell types — monocytes, B and or cD8 T-cells — were not demonstrated as being significant HIV reservoirs at this early HIV disease stage. This is perhaps of limited general applicability, as most people are not identified so close to infection. But it does highlight the very early seeding of reservoirs and how this might be reduced. One report based on laboratory studies suggested that the size of HIV reservoirs of HIV proviruses, which are capable of initiating replication, may be up to 12 times larger than previously thought3, while another identified a new subset of memory T-cells (T Memory Stem cells), which in the long term (more than 10 years) demonstrated an increasing contribution to total HIV reservoirs4. This new finding suggests that this subset of T-cells may contribute to viral persistence and may also contribute to viral rebound when you stop or fail treatment. not currently supported by treatment guidelines — after which time they were able to maintain an undetectable VL for an average of 89 months with no viral rebound and maintain average CD4 counts of 837 cells/ mm³. In some ways, the Visconti

are associated with a risk of HIV progression, and, in contrast to elite controllers, possess few markers that might protect them from HIV progression. They have very weak or undetectable CD8 Tcell responses, and their capacity to suppress HIV is low. So, genetically and immunologically

they are quite distinct from elite controllers. However, like elite controllers, their HIV reservoir levels, as measured by HIVinfected resting memory CD4 Tcell subsets are low, and continue to decline. These 14 individuals, now called post-treatment controllers, represent an example of what a functional cure might look like. Undoubtedly they will be monitored for many years. From this large cohort of French PLHIV followed from 1997 to 2011, only 756 began treatment within six months of infection and received at least one year’s treatment. Of these, 70 ceased treatment and had subsequent viral rebound. While these results certainly add to the growing evidence of the benefit of early initiation of treatment, the study authors suggest that even for individuals who begin treatment very early, within six months, the probability of being able to maintain an undetectable VL if treatment is ceased is only 10-15%. The vast majority of PLHIV, even those who are diagnosed and commence treatment at the very earliest, that is, within two months of infection, will need to stay on treatment to control their HIV. The overwhelming consensus of HIV clinicians is that once commenced, treatment should not be discontinued. The 14 cases in the Visconti cohort are exceptional, and provide no argument for stopping treatment at least until more is understood about how they were able to control their HIV infection. WHAT DOES THIS MEAN FOR PEOPLE RECEIVING HIV TREATMENTS? Advances in understanding the nature and size of HIV reservoirs continue to be made, and the evidence of the benefit for limiting reservoir size by very early treatment has also been advanced. However, the task of purging HIV from its reservoirs proceeds slowly. So, are we any closer to finding a cure? Yes. But are we there yet? Sadly, no. While we wait, our best bet is to maintain our health by suppressing the virus on treatment and doing all the other things necessary to stay well. And to keep watching this space.

2013 1 cROI Abstract #50lB; 2 cROI Abstract #47; 3 cROI Abstract #43; 4 cROI Abstract #44. Additional references can be found in the web version of this article at napwha.org.au/pl. nOTeS fOR neWS fROM cROI

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Affordable housing is a basic right, but for those living with HIV and on a low income it doesn’t always come easily. James May knows only too well from personal experience.

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A place to call my own

WHEN I FOUND OUT I WAS HIV positive thirteen years ago, I left my home in Sydney and spent the next year coming to terms with the virus in San Francisco. The rental market was twice as expensive as Sydney and I no longer had a network of friends to fall back on. I discovered many people living in what were known as ‘flophouses’ — a last resort in a skyrocketing rental market. I found a place that was gay-owned and operated and offered tiny rooms for US$200 a week. It was share bath and shower with no kitchen facilities. Most of the residents were gay men and many were living with HIV. Some were clearly disabled by the virus and had shocking deformities from early drug treatments. I was surprised to see PLHIV living in this type of accommodation; however, when I returned to Australia and moved to Melbourne a year later, I noticed similar places popping up all over the city. I was physically and emotionally frail and felt too vulnerable to disclose my HIV status to anyone, let alone share accommodation with them. I was unemployed and in no position to apply for private rental through a real estate agent, so I had little choice but to try the rooming houses. The first place I called home was like a medieval castle on the outside and a rabbit warren of gloomy rooms with musty carpet and shabby beds on the inside. There was a communal kitchen for up to fifty residents — nigh impossible to prepare nutritious meals without some drongo with a ciggie and a UDL breathing down your neck. There were two bathrooms with a handful of showers, so very little privacy even when you could get one. The main problem was the residents — mostly men, often aggressive, intimidating and ‘straight’ — though you wouldn’t know it when they staggered home from the pub and gave you a ‘sexy’ wink. It’s hard to be gay in such a place, let alone HIV positive. You have to hide it when you’re unwell. You have to put on a brave face and fit in with the ‘boys’.

I tried various places around town — often run-down with poor facilities, crook landlords and dodgy residents. I recall one joint above a restaurant. No one was assigned to do the cleaning. The bathroom was caked in mould, the kitchen thick with grease. Some rooms had no ventilation or windows and there were no leases or rent receipts. They had regular karaoke gigs downstairs and our floors throbbed all night from drunk women singing Cher and Shania Twain songs. Thankfully, Club 80 was just around the corner and offered a welcome respite. The owner of the restaurant sold up one day and we barely had time to leave. I moved to a swanky place above a laundrette where dryers churned day and night and the rooms sweltered like sauna cubicles — without the benefits. Six years after the diagnosis, I decided I wanted out of rooming houses. I wanted a real home. I was studying full-time and my health was strong. I thought I’d keep my HIV status a secret and try my luck in a sharehouse. It turned to shit pretty quickly. I had a personality clash with one of the housemates. I developed insomnia and chronic fatigue. Our clashes became more hostile. I lost weight and developed a dry, hacking cough. I stayed with a friend for a short time before getting rushed to emergency with MAC (mycobacterium avium complex) and PJP (pneumocystisjuroveci pneumonia). After being in hospital for a month and climbing the walls to get out, I realised I had nowhere to go. Thankfully, I was given a room in a supported accommodation service through The Alfred Hospital, but there was always pressure to move on. Six months later I was placed in transitional housing and two years after that the Department of Housing offered me a permanent place. My health improved out of sight with my own space to navigate the challenges of living with HIV. I finished my uni course, made some good friends and got my life back on track. MANY PEOPLE LIVING WITH HIV face similar struggles in their efforts to find safe and affordable housing. According to the 2009 HIV Futures Survey Six, 13.4% of PLHIV were living in public housing and 3.3% were in community housing. Almost a quarter (23%) had changed their accommodation as a result of HIV and 7.9% had experienced less

favourable treatment in relation to accommodation. Some 42% said their main source of income was some form of government benefit or pension and the report also found almost a third (31%) were living below the poverty line. Liz Crock is an HIV Clinical Nurse Consultant with the Royal District Nursing Service (RDNS) in Melbourne. The service works in partnership with the Victorian AIDS Council (VAC) to provide community care and support to PLHIV in their homes. According to Liz, around 95% of their client group lives in some form of public housing. She says there are more and more PLHIV in private rental who can’t afford to stay there. They are on long waiting lists for public housing and are being pushed further and further out to the fringe suburbs, where access to public transport and medical and HIV services is poor. ‘We have one client, a refugee and single mother living in private rental. Her pension was recently cut under the government’s new rules for single parents. She has to find work but can barely speak English. She’s still recovering from various comorbidities including TB and HBV-related liver damage, and trying to pay $300-400 a week for a two-bedroom house with three kids.’ The staff at RDNS often see PLHIV whose circumstances have changed because of sudden illness. They also see many who are newly diagnosed and very sick; they weren’t even aware of their HIV status because they’d never been tested, says Liz. As well, some PLHIV may have been in paid work, but had fallen ill with an AIDS-defining illness. ‘They’ve lost their job and can’t sustain private rental so they wind up in a rooming house or with family who don’t know about their sexuality or HIV status,’ she adds. The RDNS also gets referrals through the RDNS Homeless Persons’ Program and visits PLHIV in rooming houses and crisis accommodation services. Another RDNS caseworker spoke of one client who was hospitalised with an AIDSdefining illness for a month and has now been living in crisis accommodation for six months. ‘He needs stable accommodation. His health is deteriorating. It’s hard for us to get access to him and hard for him to take medication. There are many unstable people and a lot of drugs and alcohol in crisis

accommodation.’ Heather Morgan is the Team Leader of Community Care and Support services at the Positive Living Centre (PLC) in Melbourne and says she meets clients who face a housing crisis all the time. ‘Now people are living longer with the virus they are put on regular waiting lists with everyone else in the community. Some people are placed in boarding houses, which can have terrible conditions. We know one guy who went to a boarding house and was bashed. He got out of hospital and was put up in a motel where his things were stolen. Some people are living out of their cars,’ Heather says. People feel lost without secure housing, says Heather. Housing is a major safety net that helps people move on in life. ‘Once people get a home and feel safe they can get on with other things,’ she says. ‘Having privacy makes a big difference.’ Deidre Byrne is a Client Care and Support Officer and InHome Support Caseworker at the PLC. She says she used to see PLHIV in need of housing once or twice a month; now it can be up to three a week. ‘Life changes dramatically when people get their own space,’ Deidre says. ‘They can finally settle and everything else falls into place.’ Housing Plus is the main organisation that staff at the PLC liaise with to find suitable accommodation for clients. ‘They are fantastic. They’re transparent and communicate with us regularly,’ Deidre says. ‘They’ve provided transitional housing to many of our clients without long delays. They respond to our requests swiftly and consider clients’ needs carefully.’ Housing Plus offers statewide assistance to PLHIV to find housing in Victoria. This includes providing information and referral, advocacy in dealing with other agencies, help with making applications and also case management where necessary. Naomi Gidon is the case manager and says the service is available to all PLHIV who need it. ‘We place people on a priority housing list and also get them placed on waiting lists with other housing agencies in the region. We help clients find long-term housing and refer clients onto crisis accommodation services, if need be. We continue to advocate for them until they are given funds for temporary

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accommodation,’ she says. According to Naomi, Housing Plus has been consistently busy in the last twelve months and there is no sign of that letting up. ‘The increase in private rental costs is increasing the demand on our services,’ she says. Many PLHIV find it hard to find housing because of physical and mental health problems, unemployment and a lack of personal support. Relationship breakdowns can often lead to a person winding up on their own and finding it tough to cover the cost of private rental. ‘Some PLHIV don’t feel comfortable sharing because of discrimination and issues around taking medications and side effects,’ she says. Naomi says Housing Plus has had a number of successes for some of the most vulnerable people.

should be made aware of the situation.’ FOR MANY OF US, LIVING with HIV means that physical and mental health will be compromised at times. Many of us don’t feel comfortable sharing a home with strangers and we can’t always disclose our HIV status without fear of prejudice. Some people are diagnosed with HIV when they don’t have the financial means to pay for private rental, nor do they have friends or family to fall back on. Some PLHIV are chronically ill and will always find it difficult to cover the cost of private rental. Living well with HIV requires decent living conditions, which means it has to be low-cost and with adequate facilities so we can care for ourselves. We need space and comfort to deal with the physical and emotional

I’VE NOW BEEN LIVING IN PUBLIC HOUSING FOR FIVE YEARS. I’M VERY GRATEFUL FOR THE SPACE BUT IT’S HAD ITS OWN CHALLENGES, SUCH AS NEIGHBOURS WITH DRUG, ALCOHOL AND MENTAL HEALTH ISSUES. DESPITE THIS, MY OWN HEALTH AND QUALITY OF LIFE HAVE REACHED LEVELS THAT WERE UNTHINKABLE WHEN I WAS MOVING FROM ONE ROOMING HOUSE TO THE NEXT. ‘Their outlook on life and overall health has improved. They have more social contact. They have peace of mind and security. It especially makes a difference for people with kids,’ she says. Naomi mostly sees gay men but also some women and families, including people from CALD backgrounds. ‘There seems to be more young clients coming through,’ she says. ‘We also have older clients who were diagnosed late and are now very sick and experiencing a housing crisis.’ Naomi argues there is not enough government funding for housing agencies nor enough community awareness. ‘We need to put more policy proposals to the government for more funding. People who are at risk of homelessness are not always visible. More people

challenges that living with HIV brings. A stable home is the foundation for strong health and a good quality of life. It’s not something we should have to struggle or compete for. It’s a basic human right. I’ve now been living in public housing for five years. I’m very grateful for the space but it’s had its own challenges, such as neighbours with chronic drug and alcohol/mental health issues. Despite this, my own health and quality of life have reached levels that were unthinkable when I was moving from one rooming house to the next. It’s simply impossible to establish friendships, work and study routines and care for your health in these circumstances. I do hope to leave public housing one day. For me, the next step would be a house with a garden, maybe a partner — or a pet.

runny nose, phlegm, watery eyes, loss of energy and muscle aches. The infection usually lasts about one to two weeks, and most people recover within this time without requiring medical treatment. For some, it can take longer, so see your doctor, particularly if symptoms are severe or you have a high fever (above 38°C) that won’t come down (Tip: buy a thermometer). While colds and the flu are caused by different viruses — leading to different illnesses — some of the approaches to combat them can be similar, depending on symptoms. But treatment of both viruses tends to comprise symptomatic relief, while the best prevention is afforded by the annual flu vaccine.

Winter is with us again and along with it comes the usual risk of colds and the flu. Peter Watts suggests some timely remedies, including the flu vaccine. n ounce of prevention is worth a pound of cure, as they say. And so, as we begin the winter months, it’s once again time to recharge the batteries. Build up your immune system with adequate sleep (see back cover story), exercise, ample fluids (water) and warming and hearty meals based on fresh seasonal fruits and vegetables. Diets rich in vitamins A (carotene), C, E, B6 and B12, and the minerals iron, zinc and selenium are key nutrients that boost the first-line immune defences. Supplementation is generally not recommended, unless your diet is low in these. There may be some exceptions, such as the ageold naturopathic preventative cod liver oil (rich in vitamins A, E and D); these fat-soluble vitamins store in the liver, so you need only take cod liver oil every few days. Or vitamin C, which doesn’t store in the body and is required daily, is particularly important if you’re a smoker or under stress, both of which deplete vitamin C more rapidly. Taking a zinc supplement before the flu season begins may also help, but check with your healthcare provider first. Attention to personal and home hygiene will also help ensure you reduce the risk of breathing in any circulating cold and flu ‘bugs’. Disinfecting household surfaces and washing your hands regularly in warm soapy water are particularly important.

HEALTH RISKS OF COLD AND FLU Colds are not caused by cold weather, but by a virus, which predominates in the colder months. When people are indoors more, colds tend to spread from person-to-person. Generally, a cold will resolve in a week or two. But if you do catch a cold, it shouldn’t be much of a

PHOTO WRAgg

TIPS TO BEAT THE

THE FLU VACCINE There are a number of flu vaccines, although all have the same ‘ingredients’ (inactivated ‘dead’ virus isolates), making it impossible to catch the flu from having the vaccine. However, there is a remote possibility of still acquiring the flu because some people do not respond to the vaccine. The level of protection offered by the vaccine is generally between 70-90%, and so if you do get the flu despite being vaccinated, severe symptoms and complications are significantly reduced. Six vaccines are registered for use in Australia for the 2013 season, although only three are free for all PLHIV (aged six months or older) under the National Immunisation Program.

WHY DO WE NEED A VACCINE EVERY YEAR?

concern to the immune system, even for PLHIV. Of bigger concern for PLHIV is influenza, because it can reduce CD4 counts, which can be more problematic if you have a low CD4 count. One of the risks of getting the flu is that it can also lead to pneumonia. A five-yearly pneumonia vaccine is available

that prevents streptococcal viral causes of pneumonia; however, how relevant it is to your health needs may depend on your immune counts and your doctor’s advice. But the flu vaccine is certainly recommended annually for all PLHIV regardless of CD4 counts, because you don’t want to lose any of them to the flu!

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SYMPTOMS OF FLU Generally, flu attacks mainly the upper respiratory tract — the nose, throat and bronchi (branches of the wind pipe that go into the lungs) — but it can affect the whole body. It can result in severe symptoms, including fever, chills, headache, sore throat, cough, stuffy head,

Each year, the major circulating flu viruses tend to change, so the vaccine is updated to include the newest flu virus strains. Also, the protection the body offers after being vaccinated declines over time. So, one year after being vaccinated, the levels are low and may not protect you, even if you had the same strain of vaccine in previous years as is in the current year’s vaccine. People with low CD4 counts may not get the desired antibody response from the vaccine, but they are most at risk of getting the flu and possibly can be more severely affected by it. A recent US study, reported at the 2012 CROI Conference, investigated vaccine response among PLHIV by comparing the standard-dose vaccine with a high-dose vaccine. The high-dose vaccine won out with statistically greater antibody

responses to the various flu strains; this trend was even more pronounced in people with CD4 counts below 200. However, until more conclusive studies are done, the standard dose will continue to be given.

BENEFITS OF THE VACCINE The flu vaccine doesn’t protect you from catching the common cold, because colds are caused by a different group of viruses for which there is no vaccine; but colds are not generally a serious debilitating illness like the flu can be. The protection given by the flu vaccine becomes evident when we look at the number of people affected by the flu, who are generally not vaccinated. In 2012, there were 41,981 laboratoryconfirmed cases of influenza in Australia; 9% of these patients were admitted to intensive care. There were 60 reported influenzaassociated deaths, but this is likely to underestimate the true number. Influenza disproportionally affects the elderly, children and people with immunecompromised conditions. PLHIV who have CD4 counts below 200 may respond less well to the flu vaccine, where the vaccine may not ‘take’. If your CD4 count is higher, the vaccine can be as effective as it is in people who don’t have HIV. There is some evidence that the vaccine leads to a short-term rise in viral load, but this is not considered a real concern, and it needs to be balanced against the risk of CD4 decline that a ‘real’ attack of the flu would have. There is no definite answer about whether to have the flu vaccine or not — the decision lies with you and your doctor, based upon personal and clinical needs.

SIDE EFFECTS The most common side effect of taking the vaccine is soreness at the injection site, usually the shoulder muscle, which may last up to two days. While many people do not experience any side effects, sometimes people may have mild respiratory symptoms — cough, wheeze, chest tightness, red eyes — but they are not influenza, and tend to resolve within 48 hours. As the virus used for influenza vaccines is propagated in hens’ eggs, you should avoid it if you have a known history of serious allergic reactions to eggs. The vaccine should also not be given to people who have a fever associated with another illness.

WHEN TO HAVE THE VACCINE Temperate regions generally experience flu epidemics from late autumn to spring. In tropical and sub-tropical regions they can occur throughout the year, with one or two peaks a year. The flu virus does favour the colder southern states, however. The best time to have the vaccine is during autumn (March-May). But you can still vaccinate in winter, remembering that immunity may take about two weeks to develop. (There’s more information on flu vaccines from the National Immunisation Hotline on 1800 671 811 or immunise.health.gov.au.)

WHAT IF I DO GET A COLD OR THE FLU?

simplest method is to fill a bowl with steaming hot water, to which you have added a drop of any menthol oil, including eucalyptus, wintergreen, peppermint, lavender or tea tree. Then put a towel over your head and place your head over the bowl and inhale the fumes. Keep your eyes closed, because the vapours can irritate your eyes. You can also place a single drop of peppermint oil at the back of the

friend, neighbour, or community nursing service if they can help you to the doctor.

CHEST VAPOUR RUBS AND COUGH MEDICINES MAY HELP NIGHT COUGH, CONGESTION AND SLEEP.

WARM SALT-WATER GARGLE MAY ALSO HELP CLEAR THE THROAT AND HAVE A STERILISING EFFECT.

and availability in the body. The standard dietary recommended daily dose of vitamin C is 2550mg.

ZINC THROAT LOZENGES MAY BE EFFECTIVE IN SHORTENING RECOVERY TIME FROM COLDS AND FLU. Zinc supplements that you swallow won’t work as well for localised treatment as the zinc needs to coat the lining of the

Kick-a-Germ Joy Juice DRy HeRBS

BenefITS

1 cup chamomile ½ cup sage

calms, relaxes antibacterial, anti-fever properties, antispasmodic to relieve cough and sore throat contains thymol to relieve irritated throat

Whether you have the flu or a cold, the symptoms can be treated in similar ways, although flu symptoms can be more severe and include fever, and require closer medical attention. As most colds and all flus are caused by viruses, antibiotics don’t work for them; they work against bacteria. Here are some tips to help alleviate symptoms.

½ cup thyme 1 cup echinacea* 2 tbsp fenugreek balances blood sugar levels, induces sweating to expel fever 2 tbsp rosehips high in vitamin C cHAMOMIle flOWeRS 2 pinches cayenne pepper induces sweating, has warming effect

fReSH IngReDIenTS

BenefITS

1 lemon wedge

leave skin on and squeeze to extract lemon oil, which contains d-limonene, useful for gastrointestinal upsets and as an antioxidant for chills, soothing to the stomach germ-fighter Medihoney or Manuka honey has superior antibacterial and antiviral properties

KEEP WARM AND STAY OUT OF EXTREME WEATHER. Stay in bed if need be; a hot water bottle can help to keep your feet or body warm. A steamy hot shower with the bathroom door closed helps clear your airways and any mucus in your sinuses. If you’re feeling weak, sit on a stable plastic stool or chair in the shower.

combine all and mix, store in a jar in a dark, cool place. To prepare, take 2 teaspoons of the herb mix, and add:

1 tsp ginger, diced 1 clove garlic, chopped 1 tsp honey

ecHInAceA flOWeRS

DRINK PLENTY OF FLUIDS. Sip some sweet fluids, such as lemonade, which can help to keep your energy levels up a bit. Hot drinks containing water, lemon and honey can also help. (See Joy Juice, AT RIGHT) Easy-to-prepare soups with fresh chopped vegetables will provide some sustainable energy and nutrition. In-season fruit and vegetables, including citrus, is also good, especially when juiced. Some people find eliminating dairy products for the duration of their cold or flu helps reduce any mucus build-up in the nasal and chest cavities.

ANTIHISTAMINES, NASAL DECONGESTANTS AND STEAM INHALATIONS CAN HELP REDUCE THE STUFFINESS AND BRING UP CONGESTION. Steam inhalers are available at chemists, but the

Put all ingredients into a teapot and add boiling water. leave to stand 3-4 minutes. Strain and sip as needed. you can also gargle with the mixture. you can make this remedy ahead of time and keep it in the fridge, then just warm or add hot water when needed. It’s best to use it at the first sign of infection. The remedy can make you hot and your sweat will smell like curry (due to the fenugreek).

*echinacea may help speed recovery time, however, you should limit use to the short term only, since this herb can increase an immune system chemical called Tnf-alpha, which has been linked to HIV disease progression. As well, the herb may interact with protease inhibitors. It would be best to discuss the pros and cons with your healthcare provider before using echinacea. Echinacea angustifolia may be the most potent species, as compared to E. purpurea.

ROSeHIPS

PHOTOS: DADDy9 (cHAMOMIle), BAnAnAS (ecHInAceA), MORn THe gORn (ROSeHIPS )

roof of your mouth to help ease a sore throat; not more than a single drop, though — too much and it’ll burn.

PARACETAMOL, ASPIRIN, OR IBUPROFEN MAY HELP REDUCE ANY FEVER, HEADACHE AND MUSCLE ACHES, but they won’t reduce the course of infection. Use only as directed and if you’re very unwell, call your doctor or ask a

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VITAMIN C IN HIGH DOSES — UP TO TWO GRAMS — CAN HELP REDUCE THE SEVERITY AND DURATION OF A COLD, but it may have minimal benefit for the flu (except as an antioxidant and in chewable form can help soothe a sore throat). High doses can cause diarrhoea, so don’t overdo it! You can limit vitamin C with a lower dose by taking it with aspirin to increase its absorption

throat. Zinc supplements work better to prevent infections, but they may improve recovery time and help build resistance to further infections if taken at the onset of a cold or flu. Even if you end up with the flu this winter, remember the vaccine for next year and, in the meantime, try these tips to reduce your risk of a cold and to stay well in general.

DOCTOR LOUISE ANSWERS YOUR QUESTIONS

what’syourproblem?

Chris from Byron Bay, NSW writes: I have a slightly sore throat that’s been hanging around longer than a cold normally would. I’m worried I might have an STI. How do I know if I have contracted one? Dr Louise replies: Thanks for your query, Chris. Sore throats can be caused by a number of different viruses and bacteria. While most are not caused by sexually transmitted bugs, gonorrhoea and chlamydia can both cause infection in the throat region so they should be considered as possibilities — as should syphilis, which can also cause a throat infection. Chlamydia often doesn’t have any symptoms and is picked up on routine screening. Here’s some more information about gonorrhoea in particular. Neisseria gonorrhoea is a bacterium that is able to survive

and cause infection in a number of different parts of the body. Gonorrhoea is transmitted by unprotected oral, vaginal and anal sex. Symptoms depend on the site of infection, but most usually the urethra, throat, anus or cervix is affected. As mentioned previously in What’s Your Problem, if the site of the infection is the urethra, there is often a discharge of thick, yellowish pus from the penis. This is often accompanied by pain and discomfort during urination. With anal infection, there can be a mild discharge, anal pain or itching. Usually symptoms show up quite quickly, typically about 2-5 days after infection, and people often notice these and

PHOTO BRIDIxOn

A sore throat or something else?

present for a check-up. However, sometimes there may be no symptoms. The bug can be transmitted from the penis to the throat region (pharynx) during oral sex. Quite often there will be no

symptoms and at other times there may be a suggestion of a sore throat or tonsillitis. This is why it’s important to have regular STI checkups. The presence of one STI (e.g., gonorrhoea) increases the risk of transmission and acquisition of other STIs, so it’s best to get tested and treated as soon as possible. There are lots of good reasons to get regular STI checks and the fact that bugs can be present without you knowing is one of the best. A thorough check-up is really quite simple and involves having throat and anal swabs along with a urine test to check for the presence of chlamydia and gonorrhoea, and blood tests for syphilis, hep B and hep C — and an HIV test for those who are not known to be positive. The STIGMA guidelines (http://stigma.net.au/resources/ STIGMA_MSM_Testing_ Guidelines_2010.pdf) suggest how often you should get tested, depending on the number of partners you might have.

Gonorrhoea is easily treated with an injection of the antibiotic ceftriaxone and chlamydia with another antibiotic, azithromycin. It is extremely important to tell all your sexual partners from the last three months that you have been diagnosed with gonorrhoea and ask them to be tested and treated. If you are finding it difficult to tell partners, your doctor can give an anonymous letter, or you can go to the website letthemknow.org.au and send partners an anonymous SMS or email message. Practising safe sex by always wearing condoms for oral, vaginal and anal sex is the best way to prevent further infections. keep your questions under 100 words and email them to pl@napwha.org.au. n Dr louise Owen’s advice is not meant to replace or refute that given by your own health practitioner, who is best placed to deal with your individual medical circumstances.

SUPERfoods the lemongrass, use the back of a knife and bash the stalk so it splits). Sauté for two minutes without browning. Add the cold water and bring to the boil. Then add the Tabasco, soy sauce and fish sauce. gently lower the salmon fillets into the broth and turn down the heat. Simmer for four minutes until the salmon is cooked.

You loved her recipe for beetroot and goat cheese tart, so we asked Jo Watson to cook up something special for winter.

Salmon and ginger broth photo by Rafal gaweda

The Atlantic salmon used in this comforting broth is one of the world’s top superfoods. Salmon is a rich and naturally occurring source of omega-3, which helps lower bad cholesterol and prevents coronary heart disease, high blood pressure, rheumatoid arthritis and depression. Salmon is a highly nutritious food containing protein, vitamin A, a range of B vitamins and vitamin D, as well as the minerals calcium, copper, iron, magnesium, manganese, phosphorus,

potassium, selenium, sodium and zinc — all of which are vital ingredients for a healthy balanced diet. SeRVeS

2 Remove the salmon and

leave to one side. Add the vegetables and bring the broth back to the boil. Simmer until cooked (3-4 minutes).

Method 1 lightly heat the sesame oil in a large pan. Add the garlic, ginger, onions and lemongrass (to crush

3 finally, add the lime juice and the grated rind. Place the salmon in bowls and pour the broth over each dish. finish with freshly chopped coriander.

2 tablespoons sesame oil 1 teaspoon garlic, chopped l 3 teaspoons ginger, chopped l 2 red onions, chopped l 2 lemongrass stalks, cut in half and crushed with the back of a knife l 700ml cold water l A shake of Tabasco sauce l l

3 teaspoons of soy sauce 6 teaspoons fish sauce l 4 x 100g salmon fillets (skin removed) l 3 spring onions, chopped l 1 large handful of bok choy l Small mix of mushrooms (enoki, brown, oyster)

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Juice of 1 lime and rind of ½ 1 tablespoon chopped coriander

stateOFMind THE COLUMN WHERE THERAPISTS RECOMMEND TECHNIQUES WE CAN EMPLOY TO DEAL WITH THE SYMPTOMS OF ANXIETY OR DEPRESSION

Our body is always in the present moment. It is never in the future or in the past. Our mind, on the other hand, is all over the place, projecting into the future our worries, fear or plans or ruminating over our past, when we rehash conversations or revisit emotional wounds or try to rewrite history in our heads. Whenever our awareness is caught up in the future or the past, we miss out on all the possibilities of the present moment. It is in the present moment that we have access to our humour, joy, wisdom, insight, creativity and intuition. The presence of these qualities is an invaluable asset if we want to live a full and meaningful life. Coming to your senses can become a moment-by-moment way of living that gives you constant access to these treasured qualities. Even while you are reading these words, open your awareness to the weight and posture of your body. Be aware of how and where the chair — or whatever is supporting you — holds your body. Feel the touch and texture of your clothing against your skin; notice the temperature that your clothing helps create; feel the soft movement of the air against your hands, your cheeks. Become aware of any taste in your mouth, notice how your eyes are travelling along the page to read these sentences. Become aware of all the sounds within and around where you are right now. Let your listening travel out until you hear the sun shining or the clouds passing by. Then become aware of the

learning to meditate can often seem forced or difficult. Petrea King guides us step-by-step through a simple meditation for a moment-by-moment way of

Living in the

PRESENT PHOTO PIxDeluxe

When I was in my early twenties, I suffered crippling anxiety and panic attacks. Although meditation was already part of my life, the simple practice of coming to my senses proved to be an invaluable tool for managing tumultuous feelings.

breath as it flows in and out of your body; the rise and fall of your abdomen or the soft movement of your clothing against your skin as you breathe. Feel the expansion and contraction of your rib cage with each breath. Notice the difference in temperature between the inbreath and the outbreath as the air is warmed by your body.

If thoughts, sensations or feelings come, don’t resist, judge, label or add to them. Simply allow them to come, to pass. In this way, you are aware of what ‘is’ without any need to have it be any different. Just as the clear blue sky (of awareness) doesn’t get itself into a tizz over the clouds passing through, likewise, you simply

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observe the thoughts, feelings and sensations without comment or involvement. This is such a simple exercise and there is no waking moment when you can’t practise coming to your senses. You will find that all mental activity begins to subside and you are more focused and present to each activity or moment. In this way, meditation

becomes a way of life, not just a formal practice once or more a day. We can live each moment of our lives, consciously aware of all that surrounds us and is within us. From this inner equilibrium, we respond open-heartedly, moment-by-moment to life’s encounters. This is living in heaven. We don’t meditate to become fabulous meditators. We meditate so that we are more easily able to liberate ourselves from the judgments, attitudes, resistance, beliefs, thoughts and patterns that are second nature to us. This enables us to reveal and experience our first or essential nature. Human endeavour and achievement are often brought about through struggle, strain and tension whereas in meditation or by coming to our senses, we relax into a deeper sense of ourselves. The regular practice of meditation gives us greater presence of mind. With this comes the possibility of choice: we can continue to react to the events of our lives from our unprocessed emotional history or make a more appropriate response. Until we are present, aware and awake we don’t see the choice, we simply react. It is liberating when we react less to events in our lives and have a greater ability to respond to them instead. Meditation and coming to our senses liberates us from these thoughts and feelings as we develop our ability to witness and release them, but not react to them. In this way, we choose new and more appropriate responses to life situations. The more present we are to our own lives, embracing each moment without judgment, the more alive we become. Connecting with the senses of the body can become a constant practice. n Petrea King is a naturopath, herbalist, meditation teacher and counsellor and ceO of the Quest for life centre in Bundanoon, nSW (questforlife. com.au). She is the author of eight best-selling books.

Tosle p: perchance to . . sle p

W W

e have all suffered bouts of insomnia and difficulty falling asleep. For most people, the number one cause is stress. For some, it may be a side effect of treatment such as efavirenz, which is known to cause wild dreams in some people. For others, it may be a symptom of HIV itself, such as pain, numbness or the burning sensation of peripheral neuropathy, that keeps them awake at night. Lack of sleep affects our mood, increases feelings of anxiety and depression, and can affect our memory and ability to concentrate. When fatigued, the brain thinks more slowly and we make more mistakes. When managing a longterm illness such as HIV, good quality sleep becomes even more important. Diwakar Balachandran, MD, director of the Sleep Center at the University of Texas, says, ‘A lot of studies show our T-cells go down if we are sleep-deprived . . . And inflammatory cytokines go up.’ It is a combination that increases the risk of illness. Sleep is vital for our wellbeing. It is essential for optimal learning and memory function and critical for a healthy immune system. Digestion, cell repair and the release of growth hormones are all increased during sleep. With a few lifestyle adjustments and some simple techniques, you can improve your sleeping patterns so that you go to sleep easily and avoid those debilitating and frustrating 3am awakenings.

MELATONIN AND SLEEP An important factor in getting a good night’s sleep is a natural supply of melatonin. Melatonin

PHOTO lIfeSIzeIMAgeS

Along with a good diet and exercise, sleep is regarded as an integral part of a healthy and happy lifestyle. But sometimes it’s not that easy to catch those Z-Z-Zs. Muktakiran offers some practical suggestions for ‘sleep hygiene’, along with a simple candle meditation.

is the hormone produced by the pineal gland; its role is to govern our internal body clock: the sleep/ wake cycle. It also causes drowsiness and lowers body temperature at night. Melatonin production increases at night in the dark, and diminishes in daylight. Light and electricity disrupt the natural functioning of melatonin production. The blue light emitted by fluorescent lighting, white LED lights, and the light in computer screens, TV screens and smart phones inhibits melatonin production when we are exposed to it at night. Changing the light globes in your home to ones that emit a yellow or warm white glow can make a difference. And dimming the lighting in your home progressively over the evening leading up to bedtime can help regulate your internal

body clock. Caffeine also reduces melatonin production by up to half, for at least 10 hours after its consumption. If you enjoy coffee or chocolate, it’s best to have your caffeine in the morning. Sleep research scientist, neurophysiologist and yoga teacher Philip Stevens has clinically proven that candle gazing, a commonly practised meditation technique, significantly increases melatonin production (see below). REDUCE EMR Electro-magnetic radiation (EMR) is a form of energy with both electrical and magnetic fields that travels in waves. EMR is emitted from wireless and wired technologies, such as computers, mobile phones, wireless routers, TVs, microwave ovens, electric heating systems,

and digital radio alarm clocks. Philip Stevens recommends moving all sources of EMR at least two body lengths away from your bed. He suggests that at bedtime you turn off your wifi router, put your mobile phone into flight mode and, if you use an electric blanket, use it to warm the bed then turn it off at the wall before you go to sleep. THE NERVOUS SYSTEM, STRESS AND THE BREATH The autonomic nervous system affects the quality and quantity of sleep you get each night. It has two parts: the sympathetic, which controls the stress response, getting us ready for ‘fight-orflight’ mode when a crisis arises; and the parasympathetic, which controls the relaxation response once the crisis is over. It is known

as the ’rest and digest’ mode. The pressures of day-to-day life, and how we respond to them, can over-stimulate the sympathetic nervous system. Many of us are in fight-or-flight mode most of the time and so we tend to breathe in a shallow way, using only the chest. When we breathe like this, too much carbon dioxide empties from the blood, disturbing the body’s balance of gases. Shallow chest breathing maintains the physiological message to the body of fight or flight. When stress keeps us awake, it’s quite likely our sympathetic nervous system is still switched on. We can switch off the fight-or-flight mode by changing the way we breathe. ABDOMINAL BREATHING Abdominal breathing is a natural breathing technique that has positive physiological effects. When we breathe abdominally, the diaphragm muscle moves downward on inhalation, pushing the abdomen outward. On exhalation, the diaphragm muscle recoils and the abdomen moves naturally inward. Neuroreceptors on the wall of the main abdominal artery measure the pressure of the abdominal cavity and when they feel pressure like the one exerted in abdominal breathing, the neuroreceptors send messages to the brain to relax the body. This activates the rest-and-digest mode of the nervous system. Opinions differ on what to do if you wake during the night. Some specialists advocate getting up and doing some mindless task, such as ironing or washing up. Philip Stevens advises not to get up, don’t turn the light on and don’t start reading. Instead, go back to slow-rate abdominal breathing. n Muktakiran is trained in the Satyananda yoga tradition. She is the manager of Manly yoga, where she also teaches yoga and meditation classes.

Tips for a good night’s sleep CANDLE-GAZING MEDITATION 1 fresh air is vital while you sleep. keep the window open, even in winter. And keep your bedroom at a temperature similar to the outside temperature.

3 keep your body at least 30cm away from electrical circuitry, such as powered powerboards and devices plugged into wall switches.

2 keep the room as dark as possible:

bed.

pull the curtains or close the blinds, turn off digital devices and all standby lights. And keep the room as quiet as possible: no humming or ticking clocks.

5 Sleep at regular times: go to bed at

4 Don’t let your body get too warm in

In a dark room without any drafts, sit comfortably in a chair or on the floor. Place a candle about an arm’s length away from you, the wick of the candle at eye level, or slightly below.

1 close your eyes and become

the same time each night and get up at the same time each morning.

physically still. count 5 slow abdominal breaths.

2 Open your eyes and gaze

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steadily into the candle flame with a relaxed gaze. Don’t strain the eyes.

disappears, open your eyes and repeat steps 2, 3 and 4.

6 Practise for a maximum 2-3

3 After a minute, close your

minutes only, every night.

eyes.

7 Remember to extinguish the

4 Watch for an after-image of

candle!

the flame behind the closed eyes.

5 When the after-image

This meditation is not recommended for those with glaucoma and epilepsy.