PositiveLiving A mAgAzine for people living with hiv l summer 2012-2013
Why treatment is good for your brain
PositiveLiving THENEWS issn 1033-1788
eDitor Adrian ogier (adrian@napwa.org.au) AssoCiAte eDitor David menadue Contributors Kurt Anderssonnoorgard, sean Kelly, Jenny mcDonald, neil mcKellar-stewart, Dr louise owen, peter watts Design stevie bee Design
photos Ashm
Positive Living is a publication of the national Association of people with hiv Australia.
Positive Living is published four times a year. next edition: march 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 2042 tel: (02) 8568 0300 freeCAll: 1800 259 666 fAx: (02) 9565 4860 emAil: pl@napwa.org.au web: napwa.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 nApwA 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 photo Julos
the melbourne Declaration identifies key priorities An important part of the Australasian HiV/AiDS Conference was the launch of the Melbourne Declaration 2012. the document was developed by all the national peak HiV organisations and represents our collective position on the priority actions Australia needs to take in order to meet the targets set by the 2011 United Nations political Declaration on HiV. At the opening plenary, the President of the Australasian Society for HIV Medicine, Dr Edwina Wright handed over the Declaration to the Victorian Health Minister David Davis who will discuss the document as a part of intergovernmental negotiations on reducing HIV transmissions.
The Melbourne Declaration aims to get governments to: n substantially increase access to voluntary testing including rapid testing n enhance and increase uptake of antiretrovirals to HIV positive people n make pre-exposure prophylaxis (PrEP) available to people at high risk of HIV infection n strengthen the partnership
between the HIV sector and government, increasing resources to inform people about the latest advances in treatment and prevention and to create an enabling environment through measures such as the decriminalisation of HIV in Australia. To see the Declaration and to sign up for it, go to melbournedeclaration.com
CoNtriBUtorS (from left)
top LeFt Dr edwina Wright passes the Declaration to Victorian Health Minister David Davis top rigHt representatives from the organisations responsible for penning the Declaration (from left) ele Morrison from the Australian injecting and illicit Drug Users League (AiVL), rob Lake from the Australian Federation of AiDS organisations (AFAo), Dr graeme Brown from the Australian research Centre in Sex, Health and Society (ArCSHS), Bill Whittaker from the National Association of people With HiV Australia (NApWHA), Janelle Fawkes from Scarlet Alliance the Australian Sex Workers Association, Dr edwina Wright from the Australasian Society for HiV Medicine (ASHM), prof. John de Wit from the National Centre in HiV Social research (NCHSr)
Kurt Andersson-Noorgard offers advice on changing the way we use alcohol or other drugs l Sean Kelly writes from new zealand where the condom rules supreme l Jenny McDonald shares a couple of recipes using superfoods l Neil McKellar-Stewart continues his research into why treatment is good for us l David Menadue interviews three people with hiv from CAlD communities l Adrian ogier compiles the news as usual l Dr Louise owen talks kidney and oral health l peter Watts prepares us for starting treatment
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THENEWS
Controversy over ‘when to start’ continues A lively debate occurred in a conference session on when to start HiV treatment. A key international speaker was Professor Steven Deeks who is based in San Francisco and a member of the US Department of Health and Human Services Antiretroviral Guidelines Panel. This panel last published guidelines in March and recommended that all people should be offered HIV treatment, regardless of CD4 counts. While Australia uses these as
treatment earlier, arguing that there is currently no evidence of clinical benefit in doing so. However, Deeks put forward the view that HIV is a ‘bad thing’, which causes co-morbidities and chronic inflammation. So, if you can limit the damage early on, by stopping early T-cell activation and reversing inflammation, then this can only have a positive benefit down the track. As there is no evidence that earlier treatment does any harm, ‘unless it is proved otherwise, I
our reference guidelines, the majority view of the current ASHM commentary panel released in May argued that the recommendation should remain with starting between 350 and 500 CD4s unless people are symptomatic at higher counts. This was an interactive audience and panel session and allowed good coverage of the various views people hold on this hot topic. Some Australian doctors from the audience were not in favour of initiating ARV
Only half of us on treatment
Last year, HiV diagnoses rose in Australia by 8.2%. that amounts to 1137 new cases total — up 86 from 2010 — and the highest number since 1992. Given the direction we want transmission statistics to be heading, this news came as a bit of a disappointment when it was announced at the conference in Melbourne. The increase is due entirely to rises in diagnoses among gay and other men who have sex with men (up approximately 15%) and largely the result of an increase in ‘newly acquired’ HIV (378 cases in 2011 versus 308 in 2010). This ‘newly acquired’ category represents HIV infections believed to have occurred in the 12 months prior to diagnosis. HIV diagnoses in other groups
Specialist clinic for over 50s Now that we are living much longer, we are prone to a range of health conditions that affect other older people. And given pLHiV are already living with one chronic condition, some of these may materialise earlier than expected. In response to this, St Vincent’s Hospital in Sydney has set up a specialist monthly clinic for people with HIV over 50 who
also have a number of other serious health issues. These might include diabetes or being at greater risk of developing cardiovascular disease. The clinic gives you the opportunity to see three specialists plus a dietician and a pharmacist, and to receive a comprehensive assessment of your health and treatments, including a scan to assess for
in situations where a positive person had a high viral load and was in a relationship with an HIV negative person. It was noted that many doctors were waiting for the results of the START trial for more evidence on the best time to initiate treatment for clinical benefit. Deeks summed up his position by saying that in today’s context of risk versus benefit, he believed all people living with HIV should be offered antiretroviral therapy if they wanted it.
HiV diagnoses up photo Angelhell
Up till now, various reports have suggested that up to 70% of people in Australia were taking HiV treatment. However, David Wilson, Head of the Surveillance and Evaluation Program for Public Health, from the Kirby Institute in NSW, claims that recent analysis shows this figure could be as low as 50%. The Australian HIV Observation Database and other estimates indicate that between 11,500 and 13,000 people are receiving ART; and as there are more than 24,000 people diagnosed in Australia, it would appear that his estimation is correct. If we reached the situation where 95% of people with HIV were on treatment and had an undetectable viral load, and better testing targeted a further 20% of the population whom it is thought do not know their status, Wilson’s modelling suggests we could reduce Australia’s current levels of infections (about 1100 per year) to around 400 cases per year. When asked about the Melbourne Declaration and how feasible were its aims to reduce HIV infections by 80% by 2015, Wilson suggested it was unlikely in this time frame. ‘But it is important to have an aspirational goal like this,’ he said ‘especially if we are to make some progress.’
will treat people above 500,’ he said. Australian physicians pointed out that currently there is no PBS approval for prescribing antiretrovirals above 500 CD4, unless other HIV symptoms are present. Others responded that symptomatic HIV can take many forms and there is flexibility in the prescribing indication which is helpful for good clinical management, and patient choice. Several doctors on the panel supported the idea of prescribing
blockages in your heart arteries and a bone density scan to look for osteoporosis. The results and treatment recommendations will then be relayed to your regular doctor. A referral to the clinic is required from your GP. For more information you can email ibac treatment@stvincents.com.au or call St Vincent’s Hospital on (02) 8382 3121.
were stable or saw modest declines. Diagnoses among women were down 7.1%, as were those among heterosexuals (down 10.8%) and people from high HIV prevalence countries (down 28%). Clearly, gay and other MSM continue to be the key group we need to target in relation to reducing HIV transmission risks and increasing HIV testing. According to the Gay Community Periodic Surveys, in 2011, self-reported HIV testing did increase in NSW, but was largely flat in other states. Reported instances of unprotected anal intercourse with casual partners also fell in most capital cities except Adelaide. All this makes interpreting the 2011 rise a bit complicated, but it
would seem likely that there has been some increase in incident infections, particularly among gay men and other men who have sex with men in NSW. New diagnoses in NSW went from 351 to 389 with newly acquired infections increasing by 33%. In Queensland, diagnoses dropped from 242 to 222. South Australia saw a significant increase from 41 to 67; as did Victoria, with numbers increasing from 280 in 2010 to 328 last year (although a majority of these diagnoses were longerterm infections). There was no real shift in Western Australia where the increase from 16 to 29 new infections was balanced by an equivalent decline in the number of diagnoses of longerterm infections.
new nnrti looks promising A next-generation NNrti under development by ViiV is currently undergoing a multi-centre, randomised double-blind phase iib trial comparing it with efavirenz in treatment-naïve pLHiV. The 48-week results have just been published and lersivirine has demonstrated itself to be noninferior to efavirenz (the current gold standard). While there were more reported
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adverse events involving nausea and headaches with lersivirine, CNS effects were much more prevalent with efavirenz. Lersivirine has demonstrated in vitro activity against a number of significant NNRTI-resistant strains of HIV and so is of interest as a potential addition to the existing range of NNRTIs. There is also a follow-on openlabel trial comparing it with both efavirenz and etravirine.
THENEWS
photo DrAbpiCs
‘Unacceptably high’ is how a world expert on anal cancer describes the current rates of anal cancer amongst HiV positive people. ‘In the US we are seeing rates of around 100 cases per 100,000’, Professor Joel Palefsky from the University of California told a session at the recent Australasian HIV/AIDS Conference in Melbourne. The rate is even higher amongst positive men at 131 cases per 100 000. This is higher than cervical cancer rates (at about 40-50 cases per 100,000). ‘What’s more,’ he said ‘the incidence is increasing at about 2% per year.’ Palefsky acknowledges that there is some debate about when to screen for anal cancer as most HIV positive people have the human papillomavirus (HPV) which causes the cancer. Without a randomised controlled trial, we will never be quite sure which people should be given further diagnostic treatment but it is generally accepted that people with highgrade anal intraepithelial neoplasia (HGAIN) should have lesions removed. He estimates that one out of every 377 positive gay men who develop HGAIN will progress to anal cancer every year. This translates as a 10 to 20% risk over a lifetime. However, over time and with increasing age, this risk of progression increases. Doctors are advised to do digital anal rectal examinations every year on HIV positive people and if they detect any abnormalities refer them on for further treatment. The SPANC study is currently being run in Sydney to look at the incidence of anal cancer in gay men and the best ways to screen for it. See spanc.org.au for more information.
getting ready to start Considering treatment? peter Watts offers some advice. Whether someone wants to treat when their CD4 count is above 500 or wait until it has dropped below 500 is the cornerstone of the current early treatment discussion. it is not that there is no evidence for starting treatment above 500; it’s just that it’s less strong than the evidence for treating between 500 and 350. According to Dr steve Deeks, who presented his views at the recent Australasian hiv/AiDs Conference, the bottom line is that there is ‘no harm’ in treating above 500 CD4 counts — useful assurance from a world expert on hiv. And over a lifetime, what is the difference between taking treatment for 33 years versus taking it for just 30? what are a couple more years when there may be much to gain and so little to lose? plus, earlier treatment may well curb the seeding of the viral reservoirs, reduce hiv inflammation, preserve the immune system from further damage, help quell depression, reduce heart disease risk . . . as well as decrease the likelihood of passing on hiv to others. the argument against initiating early treatment is often most vocal when it’s placed in the context of a way to lower infection rates. And
rightly so. the primary reason to treat hiv is for an individual’s own health needs; although prevention may certainly be a secondary consideration, particularly for those with hiv negative partners. Dr edwina wright expressed it eloquently at a recent panel discussion when she said that no one should be coerced onto treatment either for prevention or individual health, but they should be encouraged to consider treatment when their personal individualised health needs predict, first and foremost. so, the final and ultimate decision, and choice, rests with you, the person living with hiv. but before you make that decision, start by talking to your hiv positive peers. they are the ones in the know, but be careful that you don’t only get the extreme stories (all roses or all problems). look for balance by collecting a range of views. gather information on the particular treatment regimen that interests you or that your doctor has recommended. how important is one pill once-a-day? multi-drug single tablets are not the be-all and end-all. there may be a combination of separate pills that will suit you far better. include your doctor as a partner in your planning
process. make an agreement about the thresholds you both think are reasonable. As well as CD4 count, these thresholds should take account of what else is going on in your life. Cost may be a consideration (something nApwhA and its state and territory plhiv member organisations are lobbying hard to address at the moment). Contact your local AiDs council or plhiv organisation and speak to a treatment officer or someone with a good grasp on the topic. Discuss the history and evolution of hiv treatment and where it is progressing; there could also be some good reasons to wait. never think that taking treatment is succumbing to the virus or admitting defeat. regard it as getting on with the rest of your life. popping pills takes 10 seconds of your day. You then have 23 hours, 59 minutes, and 50 seconds to get on with the rest of it. if and when you do start, take them religiously (95% of the time, at least), and keep up your routine checks with your doctor. Don’t accept or put up with any problems if they arise. treatments can always be changed if you’re not tolerating or coping with them.
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Although Art has many benefits, it does not entirely suppress the inflammation caused by chronic HiV infection. prolonged exposure to such inflammation could have an effect on many organ-systems, including the brain, particularly as people with HiV age. And a decline in neurocognitive abilities can affect the speed at which information is processed in the brain. Researchers have found that reduced processing speed and other impairments in neurocognitive functioning also occur in older HIV negative adults. So, ageing specialists (gerontologists) have developed brain-training exercises to help these adults. In at least one study, HIV negative people who have done brain-training exercises reported better overall health, improved neurocognitive function and seem to be at reduced risk of depression. Spurred by these promising results, a research team at the University of Alabama that included specialists in geriatric medicine, dementia and psychology conducted a pilot study of one package of braintraining exercises in 22 middleaged HIV positive people and compared their subsequent neurocognitive performance to that of 24 other middle-aged HIV positive people who did not receive brain training. Results of neurocognitive testing showed that after 10 hours of limited brain-training exercises done over a period of five weeks, participants had faster information processing. Although this was a pilot study and there are many issues that need to be explored and resolved, the results appear promising. CAtie-news
photo tAlAJ
brain training improves processing
Anal cancer too high among PLHIV
THENEWS
bY seAn KellY As condom use falls in many countries and HiV rates continue to rise, turning to treatment as prevention (tasp) may seem a natural progression in the fight against HiV. the New Zealand AiDS Foundation (NZAF) disagrees. In the past 18 months, New Zealand has seen a more than 39% decrease in new HIV diagnoses among gay and bisexual men — the country’s most at-risk group. We believe this downward trend is as a result of our established condom
culture and a compelling argument against the introduction of TasP. NZAF Executive Director Shaun Robinson believes there are many problems with drugbased prevention; one of the keys being the messaging. ‘I worry some people will think popping a pill on a Friday night will give them a hall pass to have unprotected sex,’ he says. If men are approached by guys saying it’s safe to bareback with them because they have an undetectable viral load then it’s likely some men will hear the message: ‘positive guys aren’t
eNUF is eNUF eNUF is both a word and a sentence. eNUF is social action to resist HiV stigma and promote resilience. “What I like about the ENUF campaign is that it resists ignorance and apathy — it demands attention and discussion. It is a campaign message that is both simple and obvious, yet it draws you in to discover more,” says ENUF ambassador, Ji Wallace. Ji Wallace addressing delegates at the opening of the Australasian HiV/AiDS You can join in by Conference in Melbourne in october wearing an ENUF button or t-shirt or by ENUF will be running for the signing the 10 by 10 ENUF manifesto. You can also share your next few years leading up to the experience of stigma and resilience International AIDS Conference in by writing about it at enuf.org.au. 2014 in Melbourne.
photo theosns
New Zealand still a condom culture
infectious anymore, I don’t need to use condoms’. While antiretroviral treatments do effectively reduce HIV viral loads, they don’t stop
STIs which can go undetected and will increase HIV viral loads. Syphilis and gonorrhoea are currently at epidemic levels amongst New Zealand’s gay and bisexual community. The unravelling of an effective condom culture is a disturbing prospect for New Zealand. It would undoubtedly result in a spike in new HIV infections. It’s for this reason that the NZAF’s view on TasP is agreed with by the New Zealand HIV Forum of Clinical, Community and Government Stakeholders. Although it is acknowledged that treatment as prevention for those
NApWA now with an ‘H’ For a while now, we have been referring to ourselves as ‘people living with HiV’ or ‘people with HiV’ and encouraging others to do the same. All the time, however, the name of our organisation has remained the National Association of people Living with HiV/AiDS. A bit of a contradiction, don’t you agree? Plus it didn’t even correlate with our acronym: NAPWA — a hangover from the olden days when we were the National Association of People With AIDS. So, now we’ve updated both. It’s not a big change, but we think it’s significant.
Dropping the ‘AIDS’ from our name is not meant to disregard those of you who have lived through an AIDS-defining condition. Nor is it meant to forget the many friends we have lost to AIDS over the past thirty years. Our new name simply recognises that in Australia, today, with treatment the way it is, AIDS is an all-but distant memory. We are now NAPWHA: the National Association of People With HIV Australia. Bear with us while we adjust ourselves.
with HIV might have a secondary impact on HIV prevention, drugbased approaches will never be an effective population strategy in New Zealand. Says Robinson: ‘Why fix what’s not broken? Condoms have a proven 95% efficacy when used correctly and consistently. They remain the single most effective HIV prevention tool available.’ sean Kelly is the regional manager health services – north island for the new zealand AiDs foundation and a member of nApwhA’s treataware outreach network (ton).
New online support group if you’re comfortable interacting online, you may well enjoy the experience currently being trialled by positive outlook. The program functions much like a support group — it has a facilitator, a set number of participants and a program of activities run over a set number of weeks. The difference is that participants can log-on when they have time and interact via a message board. One of the benefits of this program is confidentiality. Participants are free to explore intimate issues without fear of being identified. It is also an ideal outlet for those who live outside metropolitan areas and are unable to access face-to-face or peer support. Visit positiveoutlook.org.au for more information or to enrol.
NOT ON TREATMENT?
Are you living with HIV? Interested in an online program supporting the lives of positive gay men? Positive Outlook is an online group program designed to enhance men's confidence, skills and abilities to deal with the psychosocial issues associated with HIV. Particular attention is focused on disclosure of positive status and managing HIV within intimate relationships. We are currently trialling this program and seeking participants. For more information or to register you interest, please visit positiveoutlook.org.au PositiveLiving l 5 l summer 2012-2013
Do you have HIV but are not currently on treatment? Researchers from the National Centre in HIV Social Research and NAPWHA are interested in your story and hearing your views on HIV treatment. n Interviews can be done over the phone or in person in urban Sydney and should take between one and two hours. With your consent, the interview will be audio-recorded; however, all information obtained in connection with study will remain confidential. n You must be over 18, proficient in English and currently not taking antiretroviral therapy. If you’d like to participate, please telephone Brent Beadle on (02) 8568 0300 or Freecall 1800 259 666 or email brent@napwa.org.au. All participants will receive a Coles gift voucher valued at $30.
Why treatment is good for your brain Last issue we looked at how HiV treatment extends life, improves your quality of life, and reduces inflammation, depression and fatigue. Now, Neil McKellar-Stewart considers some of the more specific benefits that treatment can offer . . . starting here with the central nervous system (CNS) and your brain.
How HIV affects the CNS
We know that HIV has a profound effect on our immune system and on the T-helper cells which defend us against infections. But HIV also infects the CNS, and although it doesn’t infect nerves cells (neurons), they can be injured by HIV viral proteins and by neurotoxins that are produced over the long term. Up to 50% of people with HIV who are on treatment may be living with CNS abnormalities. Most of these are mild and include things like peripheral neuropathy, myopathy (limb muscle weakness, myalgia and muscle cramps) and changes in brain structure and functioning. For most of us, HIV gets into the CNS quite early on — often within a week of being infected. Over time, it can cause an All imAges tAlAJ
immune response, inflammation and the production of chemicals (cytokines and chemokines). All this may result in damage to a range of cells, particularly in the brain. For people who are on treatment, HIV seems to affect those parts of the brain related to cognitive ability — including memory, learning, attention, and how fast we process things — losses similar to those we experience in older age. So, this intersection between ageing, HIV in the CNS, inflammation and activation of the immune system, can make it difficult to untangle the relative contribution of each. HIV treatment reduces some of these damaging processes, but it does not stop them altogether. The CNS is a reservoir in which HIV-infected cells can become active and contribute to the HIV that is circulating in the bloodstream. The extent to which antiretroviral (ARV) drugs penetrate the blood-brain barrier (BBB) depends on individual factors, the integrity of the barrier itself and also the characteristics of different HIV drugs and drug-classes (something we will discuss later).
Measuring HIVassociated neuro disorders
Neurocognitive impairment (NCI) is caused by many things, including the ageing process and a range of other health conditions such as HIV, CNS trauma, diabetes, viral infections, cardiovascular disease and psychiatric illness. Lifestyle factors such as a bad diet, drug use, smoking and lack of exercise also play a part, as do environmental contaminants. In 2007, an internationally agreed classification scheme was devised to describe the range of HIV-associated neurocognitive disorders (HAND) that were increasingly being seen in people with HIV even on treatment. This scheme is based on someone’s performance against a range of age and education standardised neuropsychological (NP) measures. There are three categories: n HIV-associated asymptomatic neurocognitive impairment (ANI), while picked up by NP measures, does not interfere with everyday functioning. The person and their immediate significant others cannot identify any symptoms of
impairment. n HIV-associated mild neurocognitive disorder (MND) does affect performance, and the person reports that they have lost some mental sharpness. They may be less effective at work, at home or socially and significant others may also have noticed these changes. n HIV-associated dementia (HAD) is the severest form of HAND and usually affects a number of areas including learning new information, processing ideas, and being able to concentrate. HAD interferes with day-to-day functioning, including work, home life and social activities. Fortunately, the vast majority of PLHIV will never experience any symptoms of neurocognitive impairment. However, if measured by a battery of exhaustive tests, a significant proportion may well be diagnosed with ANI and not even know they had it. Much fewer PLHIV will have MND. Whether or not you develop an asymptomatic or a mild NCI is strongly associated with your lowest-ever CD4 count (nadir) and with older age. It is also about the level of viral load in your cerebrospinal fluid (CSF), how much inflammation there is and how much your immune system has been activated; plus the health of your cardiovascular (blood) circulation.
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Does treatment reduce the risk of HAND? Those of you who’ve been around will know the toll that HIV can exact on people’s neurological health. Early on in the epidemic, about one in seven people with AIDS developed AIDS dementia; a diagnosis that usually progressed to severe disability and death within a year. Fortunately, with the introduction of highly active antiretroviral therapy (HAART), the incidence has reduced to almost zero. In 2002, just six years after the introduction of HAART, they estimated that cases of AIDS dementia had gone down by 60% and toxoplasmosis by 72%. Combination treatment certainly had a profound impact on these CNS manifestations. A recent review of 15 studies of neurocognitive change in people after starting treatment found that in 11 of them, neurocognitive performance improved after an average of 6 months on HAART. This is heartening news despite the fact that most of these studies had only a small number of participants. The latest ‘then and now’ comparison published in December 2010 compared 857 PLHIV from the pre-HAART era (1988-95) with 937 from 20002007. They found mild impairment occurred in both
neurocognitive impairment even when on treatment. So, does HIV treatment reduce the risk of neurocognitive impairment? Yes. But treatment is not absolutely protective. There are many other factors which come together to increase the risk.
groups at all stages of HIV disease, even in those on effective treatment. Importantly, the single predictor appears to be low nadir CD4. Sixty per cent of those receiving HAART and with neurocognitive impairment had a nadir CD4 count of less than 200. Clearly, allowing the immune system to be severely compromised increases the risk. Neurocognitive response to HAART varies across individuals, as was shown in a recent analysis of 1160 PLHIV involved in 14 different clinical trials. Investigators found that 39% of participants had some (commonly mild) impairment at the start of treatment, and that nearly half of these showed improvements after 48 weeks on treatment. However, they found that by this endpoint, 21% had also developed a new NCI. So, overall, the rate was only slightly reduced by starting treatment. Again, any history of immunosuppression was associated with higher rates of NCI. Those with a CD4 nadir of less than 200 were 1.73 times more likely to have sustained impairment, compared to those with nadirs above 350. In fact, every 50-cell decrease in someone’s lowest-ever CD4 count was associated with an 8% increased likelihood of ongoing NCI. Of 94 PLHIV with NCI in a recent Italian study, impairment persisted for nearly two-thirds of them, even after five years of treatment. A recent analysis of the CHARTER Group data concluded that the risk of NCI was lowest in PLHIV who never allowed their CD4 count to fall to low levels. Data from a Swiss cohort of 100 PLHIV on effective treatment found that 28% of them had mild neurocognitive disorders, while a further 42% had asymptomatic neurocognitive impairment and experienced no problems with everyday functioning. All these studies point to a strong association between low nadir CD4 count and an increased risk of ongoing
Shopping around for the most effective drugs Treating HIV effectively stops replication in the bloodstream (i.e., undetectable viral load); and reduces inflammation and immune activation. But to prevent HIV replication in the brain, HIV drugs must cross the blood brain barrier and be present in the cerebrospinal fluid (CSF) at levels sufficient to effectively inhibit HIV. Viral levels are not routinely measured in the CSF. A lumbar puncture is not the most pleasant procedure to undergo or without risk; and so it is only done when there is a good clinical reason.
Studies suggest that not all antiretrovirals function in the brain at sufficient levels. In 2008, a score to measure the CNS penetration-effectiveness (CPE) of HIV treatments was published. The text box (below) shows the scores for those treatments commonly used in Australia (older drugs are not included and newer drugs have yet to be scored). The total score for a combination can be calculated by adding the scores of the individual drugs. A score greater than 7 or the use of protease
inhibitors are about equal in predicting whether someone may have an undetectable viral load in their CSF. Put simply, the more effective the drug combination is in penetrating into the CSF, the more chance of HIV being suppressed in the brain. The evidence demonstrating the benefit of having a treatment regime with a higher CPE score is mixed. A recent longitudinal study of PLHIV with some cognitive impairment showed that by starting them on a treatment regime with higher CPE score for 48 weeks, their cognition gradually improved and peaked at approximately 24–36 weeks. The two factors which predicted cognitive improvements were undetectable VL in blood and a higher CPE score. Another study of PLHIV switching or initiating treatment reported that CPE scores correlated with greater improvement in concentration, speed of mental processing and mental flexibility after 20 and 39 months. Higher CPE scores were also associated with an improvement in global NP scores after 39 months. Other studies have failed to confirm these findings. Recent UK data suggests that for those on long-term HAART with no symptoms, the rates of impairment are low (less than 20%). Where impairment was found it was associated with lower nadir and older age but not CPE score or ARV drug class. So, CPE score may have some validity as a tool to guide treatment but more convincing evidence is needed, especially for those who commence treatment early. Over time, there are many variables associated with having a detectable CSF viral load. In the CHARTER Study, 413 PLHIV had their blood and CSF samples tested for detectable HIV and of those whose plasma viral load was consistently undetectable, only 6% had any measurable viral load in their
CSF. This is good news, especially as many people in this cohort had very low nadir CD4 counts and a high prevalence of NCI. It would seem that having an undetectable blood plasma VL is by far the most influential factor for indicating suppression of HIV in the CSF. This suggests that having undetectable HIV in your bloodstream usually protects you from having detectable HIV in your cerebrospinal fluid.
So, what does it all mean for me?
HIV treatment is beneficial. It drives down viral load both in the blood and in the CSF. Having HIV does put you at risk of declining cognitive function. But that risk is greatest when HIV has gone unsuppressed for many years and CD4 counts have fallen below 200. Plus there are other compounding factors including recreational drug use, co-infection with other viruses and, perhaps most significantly, just getting older. There are things you can do to maintain your brain health: n Start treatment when your CD4 counts are relatively high — possibly over 500 and certainly when they fall below 500 n Adhere to your HIV treatment regimen exactly n Ensure that you maintain an undetectable viral load. If it does becomes detectable across more than one visit, you and your doctor should talk about switching to a more potent combo
SCore
CNS penetration effectiveness (Cpe) ranks 2010 4 3 2 1
Nrtis
zidovudine (Azt)
NNrtis nevirapine protease inhibitors entry inhibitors vicriviroc integrase inhibitors note:
Abacavir emtricitabine (ftC) efavirenz Darunavir-r lopinavir-r maraviroc raltegravir
lamivudine (3tC)
tenofovir
etravirine Atazanavir Atazanavir-r enfuvirtide (t-20)
this includes only hiv drugs commonly prescribed in 2012 letendre sl, et al. (2010) 17th Conference on retroviruses and opportunistic infections, Abstract 172
sourCe:
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n Maintain the best possible cardiovascular health by ensuring that your blood pressure, lipids (cholesterol and triglycerides) and blood sugar are monitored and maintained in healthy ranges and that you follow any treatments your doctor recommends n The basics: quit smoking; limit your alcohol and other drug use; have a diet high in polyunsaturated fatty acids (omega-3s); reduce your risk of diabetes and cardiovascular disease; get adequate rest, physical and mental exercise; and promptly address issues of depression. n If you, or those with whom you share your life, have concerns that your cognitive sharpness has dulled (e.g., a lot of the time: not remembering familiar things, forgetting why you started an action, losing your train of thought in a conversation, making mistakes in everyday tasks) then talk to your doctor. Study data suggests that if a problem is suspected by the person with HIV or their close acquaintances then there may well be some underlying issue. It may be that some further investigation is suggested. n If you have been diagnosed with asymptomatic or mild impairment through neuropsychological testing, your doctor will suggest regularly monitoring. To reduce the likelihood of having further declines it is important that you stick to an optimum treatment regimen and maintain an undetectable viral load. Recent research suggests that declines only occur in a small portion of people (less than 25%) and this is usually associated with severe co-morbidities (such as hepatitis C or major depression), lifelong methamphetamine use and ceasing treatment. Finally, take a deep breath and relax: you aren’t going to go ‘mad’. If you follow the suggestions above and ensure that you and your doctor are regularly monitoring your health, the risk of serious descent into significant neurocognitive decline is very low. this article is available on the nApwhA website at napwa.org.au/pl where further reading and full references to the cited studies are listed.
Living with HIV in
another
COUNTRY David Menadue asked three people from different culturally and linguistically diverse backgrounds about their journeys, being HIV positive and moving to Australia.
When political harassment and violence forced Viola to escape her home country of Zimbabwe, she had little choice but to leave her son and daughter with their grandparents and hope that one day they would reunite. Arriving in China, she soon realised that the country was unlikely to grant her political asylum. But all was not lost. She met a Nigerian man and fell in love. And together they set off for Australia. Viola and her partner sought asylum here and as part of the immigration requirements underwent HIV testing in Melbourne. It was then that Viola
An example of ancient wooden statuary from the Shona people of Zimbabwe
photo Artist-unlimiteD
I may not still be alive if I hadn’t emigrated here.
found out she was positive. Normally, HIV has a negative impact on any visa application, but our government was convinced that if Viola returned to her home country she wouldn’t have access to treatment and her life would be at risk. So, on these grounds she was granted permanent residency. Viola and her partner married; and under the Special Humanitarian Programme she applied for her children to join them. It was then that her twelve-year-old son also tested HIV positive. She had suspicions she might have HIV when the children’s father died from AIDS several years before; although they had separated before the birth of her son. So, now it was clear she had been positive since at least before he was born. Fortunately, her younger daughter escaped
contracting the virus. A lot of stigma surrounds HIV in Zimbabwe. Before Viola left, she had heard gossip about so and so looking ill or someone else losing weight. Even her mother had expressed negative views about people with HIV; but she was not surprised when told the news about her grandson. He was always unwell and prone to infections. ‘My father was in very poor health, so telling him was much more of a worry,’ reveals Viola. So her new husband talked to him for her, reassuring him that he would look after Viola and her two children if they came to Australia. Three years later, after a difficult legal challenge with the immigration authorities, the family was finally reunited. Her son is aware of his status and ‘accepts it without any fuss,’ Viola says. ‘He takes his medications every day without
PositiveLiving l 8 l summer 2012-2013
fail and is now a hundred percent healthy.’ Viola’s son is on Atripla and has had no problems whereas she experienced a year of depression and weight loss on the drug. ‘Probably because it contains efavirenz,’ she says. ‘Finally, my doctor agreed to change me to another regimen.’ Viola has received excellent care from doctors in Australia, with the exception of one GP who admitted he ‘knew nothing about HIV’. She has a case worker with the HIV CALD service at the Alfred who helps her access services. She also attends dinners held by Positive Women Victoria where she has met other positive mothers, including some from African countries who have become supportive friends. Wary of disclosing to people in Australia, Viola has been advised that her son’s school doesn’t need to know.
‘Many Australians don’t know enough about HIV,’ she says. To date she has only ever seen one HIV message on a tram and that was quite recently. But she is grateful to be living in this country. ‘If I had stayed in Zimbabwe, it is likely I would have died,’ she says sadly. ‘Only a small number of people are on treatments and it is often only those with enough money to bribe officials who get them.’
These days, Sanjeev volunteers for an HIV agency. But until he decides where he stands on the issue of sex as an HIV positive gay man, he is taking his time deciding who to tell about his status.
Now it is not such a big deal to be positive.
photo simon gurneY
I knew little about HIV before coming to Australia.
can’t bring himself to go through any sexual negotiation around his status. He also has ‘a few trust issues’ as he felt deceived during the episode when he became positive. ‘My level of understanding about HIV was minimal when I came to Australia,’ he says. ‘I knew you could pick it up through sexual intercourse and that you couldn’t catch it from kissing and casual contact.’ But he didn’t have any deeper understanding about the relative risks of contracting HIV. Sanjeev has found it difficult to talk to anyone about his status, even within his friendship networks. ‘I am a very private person,’ he says. ‘My Indian grandmother had a great influence on me. She taught me to keep your feelings to
Until he migrated to Australia in 2006, Sanjeev remembers very little mention of HiV in Malaysia. in a country where being gay is still a social and religious taboo, he recalls even less about its particular threat for gay men. ‘As a child I recall my mother telling me not to bring home a rather “camp” school friend I’d made,’ says Sanjeev, whose Indian background he describes as religious and very conservative. ‘She didn’t think he was the sort of person our family should mix with. So to this day, I have never broached the subject with any member of my family.’ Sanjeev is still working on how out he can be about his sexuality, even in a more accepting society like Australia. ‘When I found out I was HIV positive in 2008, it added to the secrecy I carry around with me and to the level of stigma I feel,’ he says. Sanjeev has not had any sex since his diagnosis because he
Detail of wall decoration from the Batu Caves Hindu shrine near Kuala Lumpur, Malaysia yourself and to respect the social standing of your family by not sharing too many personal details.’ His greatest confidante has been his doctor in Melbourne who has taken excellent care of him. She guided him through a bumpy introduction to antiretrovirals where it took three regimens to get things right. ‘She also recommended that I adopt a gradual approach to telling others,’ says Sanjeev, ‘even to the amount of involvement I have with HIV agencies and the like.’ Even so, Sanjeev has found attending a seven-week peer support course at the Positive Living Centre in Melbourne a highly valuable experience. ‘I felt safe there. I could say things without being judged or told: “It’s wrong to think that”. Being able to speak my mind on these issues was a great thing for me.’
in 1990, Dachasa visited his doctor in the town where was living in ethiopia. He was diagnosed with pneumonia, treated and recovered, but was never told at the time that he had also been tested for HiV and that the result was positive. Five years later, when attending the same clinic, he was finally told the news. He was annoyed as he might have taken extra precautions with his health to preserve his immune system. Now he had a CD4 count of 52. But there was hope on the horizon. New treatments were being developed and he decided to take part in an access campaign in his country to try to get treatments for other people with HIV. It was 1996 and the Global Fund had started funding organisations to educate their fellow Ethiopians about HIV. Dachasa joined a group called Dawn of Hope and went out into the community to talk about how HIV could be prevented and the importance of getting tested. He even spoke to the media to try to de-stigmatise HIV and to make people aware that it was possible to live well with HIV, and that the new treatments provided hope for the future. Countries such as Ethiopia needed a lot of help to control their epidemics, so a group of Ethiopian doctors in North America arranged for a small clinical trial to show the government how well these new treatments worked. Dachasa was one of the first in his country to be put on treatment, his CD4 counts quickly increased and he looked and felt much stronger. But it didn’t convince the Ministry of Health to respond with a mass rollout. Ethiopian HIV activists, including Dachasa, then started to attend World AIDS Conferences, and to speak about the lack of treatment in their country. They encouraged the Director of the Global Fund and UNAIDS to come to Ethiopia and
convince the government of the maintain their health as a result. need to provide treatments to as but we know from the many people as possible. research that people from CAlD ‘There was much HIV stigma backgrounds often experience and fear in Ethiopia at the time,’ poorer health outcomes than says Dachasa. other Australians. this is also true Positive people and their for hiv; where CAlD are more families were routinely excluded likely to present late with an from community events. But AiDs-defining illness often treatments and HIV awareness because neither they nor their campaigns made a big difference. doctors could imagine that they ‘Now it is not such a big deal were even at risk1. to be positive. People are no maureen plain, Coordinator of longer scared to go to the doctor the Alfred health hiv CAlD for fear that people in the clinic service in melbourne, says there will spread the news,’ he says. is a need for better awareness Given the political difficulties campaigns. in his country, Dachasa sought ‘some of the positive people asylum in Australia and was who come to my service have so accepted in 2007. He was pleased little understanding of even the that the form said that if he was basics of hiv. they don’t know HIV positive, it would not affect the difference between hiv and his ability to be accepted. AiDs, the role of treatments or However, when he applied for his where to get help,’ she says. wife — who is also positive — and many believe that they will die his son, their application was because they have seen this occur initially rejected. many times in their own Dachasa is grateful to the countries. there is a lack of Asylum Resource Centre in information provided in their Melbourne. It is Australian home countries and the subject is government policy to reject not being talked about in their applications from most HIV communities here. positive people first, they told maureen maintains that many him, and helped him with the are so scared that other members appeal process which ultimately of their community will find out reunited him with his wife and their status that they will go to son. They arrived in 2011, and the family have since set up home in a comfortable public housing flat in inner Melbourne. Dachasa and his wife receive excellent care from the Melbourne Sexual Health Centre who assisted them to A man walks past a barbershop in the southern ethiopian town of Arba Minch, located about 500km conceive and south of the capital, Addis Ababa photo J CArillet give birth to a healthy baby. Dachasa worries about the extraordinary lengths to conceal level of understanding of the the fact. some will not even virus amongst fellow Ethiopians accept a translator for fear the living here. He is hesitant to news will spread. mention his HIV status to other Clearly, some broad-based community members at the campaigns within the various church he attends. CAlD communities are necessary ‘It’s best to talk about other to educate and address the stigma things,’ he says. and discrimination that still exists. tHeSe tHree StorieS show 1 A. Asanie et al. understanding how well some hiv positive late hiv diagnosis among people people from culturally and from culturally and linguistically linguistically diverse (CAlD) diverse backgrounds, national backgrounds are able to navigate Centre in hiv social research, the health system in Australia; sydney, monograph 7/2009 and how they have managed to
PositiveLiving l 9 l summer 2012-2013
DoCtor LoUiSe ANSWerS yoUr qUeStioNS
what’syourproblem?
renal health
(Nurofen, for example) are metabolised by the kidneys and should really be used only occasionally. If you require daily non-steroidal medications, let your doctor know and have regular kidney monitoring and also to determine if there may be alternatives. People on any sort of medications that can affect the
kidneys will be having regular monitoring and this will include people on tenofovir. If you have symptoms of a urinary infection, such as more frequent or painful peeing, get checked to make sure that the infection does not go up to the kidneys and cause damage. Occasionally kidney function can be reduced if there is obstruction to the normal flow of the urine out of the kidneys, either by ureteric stones, bladder problems or prostate enlargement. Cardiovascular risk factors such as smoking, high cholesterol, diabetes and hypertension (high blood pressure) also affect the kidneys. So, the message for maintaining healthy kidney function is much the same as for maintaining your health generally. It is important to drink a good quantity of fluid (water particularly) to ensure adequate volumes are flushed through the kidneys each day. Kidney Health Australia recommends water as the drink of choice to satisfy thirst. Drinks containing sugar or caffeine should be taken in moderation. Of course, we also get daily fluids from other sources such as fruit, leafy greens, and beverages such as tea.
massage. Try not to rinse after brushing as some residual toothpaste can help protect your teeth from cavities. Some people use fluoride rinses or gels as these can also help decrease decay rates. Chewing sugar-free gum after
eating will stimulate saliva and neutralise acids in the mouth. It’s important to have a diet full of fruit and vegetables and to avoid sweet snacks and drinks. Water is the best drink to quench your thirst. Cola and energy drinks contain a lot of sugar and caffeine and can reduce saliva flow. Sometimes candida (thrush) can cause tiny white patches on the roof of the mouth or the tongue and can also cause oesophagitis which can be really painful and limit your ability to eat or drink. This usually only happens when someone’s CD4 count is below 200. In this situation, you should visit your doctor for a thorough examination and they may prescribe topical antifungals in the form of lozenges, drops or oral tablets.
Mouth troubles
rolando from NSW writes: I constantly seem to have mouth ulcers. At least that’s what I think they are — small sores on the inside of my cheeks and sometime on my tongue. I use mouthwash but it doesn’t help. I’ve been positive for ten years and been on treatment for the last five (viral load undetectable and CD4s around 800); I eat well and exercise and with the exception of the odd partying on the weekend, lead a pretty healthy life. Dr Louise replies: Mouth ulcers can be very annoying and uncomfortable. Small ones that come and go are known as ‘aphthous ulcers’ and are quite painful. Spicy or acidic foods make them worse but anaesthetic mouth gels can help. They usually
traces of protein in the urine. Kidney function can be altered by a number of things. Structural abnormalities of the kidneys, such as congenital conditions, cysts or damage done by infection can alter the ability of the kidneys to do their job properly. This is usually detected by imaging techniques such as ultrasound or CT scanning. Untreated high last only a few days but if you have persistent ulcers it is important to have them checked by your doctor as they could be a symptom of something more serious, including herpes or syphilis. Chronic mouth problems are generally more common in people living with HIV; but there are ways to manage the symptoms. Quitting smoking is one. Smoking reduces the flow of saliva which dries out your mouth, worsens gum disease and plays havoc on the health of your teeth. Its effect on the circulation can also interfere with the health of your gums. What’s more, it increases your risk of developing oral and tongue cancers. Have you seen your dentist in the last six months? If not, get a checkup and a clean. (It’s a pity the Medicare Chronic Disease Dental Scheme has ended as it
blood pressure (hypertension) or poorly controlled diabetes can also cause microscopic damage to the kidney components and result in abnormal function. Potential toxins in the bloodstream can also damage the kidneys. This might be toxins from infection, medications or other drugs. Common antiinflammatory medications
photo gzAleCKAs
Dr Louise replies: Our kidneys are very important ‘housekeepers’ in the body’s maintenance system. They constantly filter the blood to remove waste and toxins; and are very involved in the regulation of chemistry and homeostasis. In particular they make three hormones: erythropoietin which stimulates the production of red blood cells; renin which is involved in blood pressure control; and active vitamin D, which is important for calcium uptake and bone health. Kidney function can be monitored a number of ways. For people living with HIV, routine blood tests usually measure electrolytes, creatinine and the function of the kidneys — the estimated Glomerular Filtration rate (eGFR). It is also recommended to test annually for
photo CreAtivestoCK
Mike from Adelaide writes: One of the HIV drugs I am on is tenofovir and I know it can affect the kidneys. My doctor has assured me that providing we monitor regularly, any abnormalities can be caught in time. But is there anything else I could be doing to ensure my kidneys stay healthy?
helped a lot of PLHIV get on top of their dental care.) As a basic principle: floss regularly and brush at least twice a day with a soft toothbrush — electric ones are best — ensuring your tongue gets a clean and your gums a good
Keep your questions under 100 words and email them to pl@napwa.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.
PositiveLiving l 10 l summer 2012-2013
stateOFMind tHe CoLUMN WHere tHerApiStS reCoMMeND teCHNiqUeS We CAN eMpLoy to DeAL WitH tHe SyMptoMS oF ANxiety or DepreSSioN
peopLe USe ALCoHoL AND otHer DrUgS (AoD) For ALL SortS oF reASoNS: to iMproVe tHeir MooD, to DroWN tHeir SorroWS, BeCAUSe tHey’re ANxioUS, BeCAUSe tHey’re BoreD. WHAteVer tHe reASoN, By tHe tiMe SoMeoNe’S AoD USe HAS BeCoMe A proBLeM, tHe reASoN HAS USUALLy BeeN LoSt ALoNg tHe WAy. SoMetiMeS, too, So HAVe JoBS, HoUSeS, pArtNerS, HeALtH.
n Where: The only place you will consume alcohol e.g., at home n When: What times will you drink? e.g., only between 4pm and 7pm and nil on Tuesday and Wednesday (having two alcoholfree days gives your body a rest) n Who with: Some people are triggers for drinking more e.g., only with Claire or alone and not with John n triggers: Some moods trigger us to drink more so, e.g., whenever when I’m sad, I won’t have drink; I will go for a walk instead. It’s very important that you write down these goals/ boundaries so you don’t forget them. And a good place to put this constant reminder is at eye level on the fridge door.
in this issue, Kurt Andersson-Noorgard talks about
CHANGING HOW YOU USE
Many people who come to see me want to continue to drink or drug but at a ‘controlled’ level. This approach is useful for those who recognise they have a problem and want to reduce the amount and frequency of the substance they use. Others are fed up with their ‘habit’ and want to stop their AOD use completely. Whichever end result you’re after, the first steps towards getting there are the same. To start with, you need to know as much as you can about the thing you want to change.
1
Get yourself a blank piece of paper. Divide the page into columns as shown below. Date it and make a record of every drink (or cone or blast) you have. Try to be specific about the amount. Standard drinks can vary from state to state so take that into account. In NSW, for example, one standard drink equals a middy of beer, 100mls of wine or 30mls of spirits. If you have a measuring cup at home, use it so you know exactly how much you are drinking. Be sure to fill in each column and if anything particularly unusual, stressful or good happens during the day, note that down as well. But make sure you record every drink (or whatever it is you are using). This will let you see how much you are really having, the pattern it takes, when are your riskiest periods, how much it is costing and even the reasons why you imbibe. You might hate doing this but stick with it for at least a week. At the end of the week have a
photo esollA
Step
Step
look at what you have recorded. Pay attention to anything out of the ordinary or spikes in your drinking. Maybe you drink more on a Saturday watching TV or before going out? The pattern can tell you something about the way you use. Knowing why you are using can help you replace it with something else. In the table, for AMoUNt
1 stubby beer
WHere
home
example, the person seems to drink to relax. So, an alternative for them could be to learn different ways of relaxing: like meditation, exercise or taking up a hobby.
Step
2
Now you have a record it is time to set some goals and limits for yourself. Be realistic. There is WHeN
5pm
WHo WitH
alone
nothing worse than deciding to never drink again only to start drinking within a few days. This can be demoralising and make you think you cannot change. What you are trying to do is set boundaries for yourself. You want to include: n Amount: How much will you drink? e.g., three standard drinks per day
MoNey SpeNt
$3.80
PositiveLiving l 11 l summer 2012-2013
FeeLiNgS
FeeLiNgS
BeFore
AFter
anxious
relaxed
3
The best laid plans can sometimes fall apart because of some unforseen event. An old friend arrives unannounced or you feel particularly anxious about an upcoming medical review. This step involves looking at some high-risk situations and planning ways you might cope with them should they arise. Include things like being pressured by friends, feeling particularly good or bad, dealing with a conflict, having access to more money than you usually do or feeling physical pain. Write them down and add new ones to the list when you think of them. Here are some examples: n If someone brings a bottle over I will pour myself a ginger beer. n If I get bad news instead of drinking I will meditate . . . play my favourite songs . . . walk the dog . . .
Next StepS For those of you who can’t or don’t want to access AOD services, here are some reputable websites that you may find really useful: n turningpoint.org.au n yourroom.com.au/Helplines n smartrecoveryaustralia.com.au n aa.org.au/ n Kurt Andersson-Noorgard is the hiv/hCv and Drug and Alcohol Clinical nurse Consultant at the h2m service at st vincent’s hospital in sydney.
SUPERfoods Not ALL FooDS Were CreAteD eqUAL — some are so packed with vitamins, minerals, antioxidants, essential fatty acids and other beneficial substances that they've been deemed ‘superfoods’. Superfoods have incredible health benefits, packing a powerful nutritional punch that can help protect against cancer and heart disease, lower cholesterol, protect the organs from toxins and improve digestive health. Some nutritionists even say superfoods can help you live longer. the berries in this delicious dessert, particularly blueberries and strawberries, are packed with antiinflammatory phytochemicals, including quercetin (which is also found in the skins of apples and red onions) and is purported to have strong anti-inflammatory properties.
For more than twenty-five years, dietitian Jenny McDonald has specialised in helping people with HiV. everything we eat should be fresh and simply prepared, she advises. But given HiV is an inflammatory condition, she also believes we should look to foods that are both calming and rich in antioxidants. Here are a couple of classic examples. they’re both super simple to prepare and perfect for casual summer dining with friends.
Gazpacho
Summer pudding
this tangy soup contains red capsicum — a superfood if ever there was. half a red capsicum has as much vitamin C as an orange, will provide your daily need of vitamin A and also delivers betacarotene and lycopene, two additional powerful antioxidants. serves four
½ red capsicum (bell pepper) ½ green capsicum (bell pepper) l 1 small cucumber, peeled l 3 spring onions l 2 sticks celery l 4 medium ripe tomatoes or l 425g can of tomatoes l 1 medium white onion l 1 cup (250ml) tomato juice l 1 tablespoon ground black pepper l 1-2 teaspoons tabasco sauce (according to taste) l Chopped parsley, for garnish l l
serves four l 14 slices wholegrain bread, crusts removed l 6 cups (900g) mixed fresh berries (strawberries, raspberries, blueberries, loganberries) l 4 teaspoons caster sugar l extra berries to garnish
Method
Method
1 finely chop
1 Cut crusts off bread and discard them. 2 Cut four round bases and tops out of the bread. set tops aside. place a base in four individual soufflé dishes. use the remaining bread to line the sides of the dishes. Do this carefully, making sure that there are no gaps. 3 wash and hull berries. Chop strawberries. 4 place berries and sugar in saucepan, and heat gently until liquid runs from berries. 5 fill soufflé dishes, packing fruit down firmly, and pour over juice. 6 Cover each with one of the reserved tops. 7 place a weight on top and refrigerate overnight. 8 remove and discard the tops. 9 turn onto serving dishes. garnish with extra berries. NUtritioN DAtA per SerVe 876 kj (209 cal), Cho 42g, protein 7g, fat 1g
recipes reproduced with permission from Diabetes Eat and Enjoy third edition Authors Christine roberts, Jennifer McDonald and Margaret Cox
PositiveLiving l 12 l summer 2012-2013
half the cucumber, spring onions, one quarter of each capsicum, one stick of celery and one tomato. set aside. 2 roughly chop all remaining vegetables and place in food processor with tomato juice, pepper and tabasco sauce and blend until smooth. 3 Add finely chopped vegetables, mix and chill well. 4 serve chilled, garnished with chopped parsley or hot with toasted croutons StorAge: Cover and refrigerate for up to three days. NUtritioN DAtA per SerVe 195 kj (47 cal), Cho 8g, protein 3g, fat trace