CD4 04

CD4 magazine FREE Issue 04/2008

! ! y l i m a f e r ea

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DIVERSITY GAY ? LESBIAN ? STRAIGHT ? BISEXUAL ?

Southern African Sexual Health Association www.sexualhealth.co.za

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Nausea and vomiting WHAT TO EAT MORE OF: ✔ Foods that are cold or at room temperature. Try a little jelly. ✔ Soft foods like rice, mashed foods and eggs. ✔ Dry salty foods like whole-wheat toast. ✔ Cold or icy beverages: lemon or ginger ale. ✔ Ginger is a great medicine for nausea. Make a tea out of a few slices. Let it cool before sipping it slowly. Try eating some ginger biscuits.

WHAT TO AVOID: ✘ Foods that smell or make you feel sick. ✘ Fatty foods. ✘ Sweet or spicy foods. ✘ Gas forming foods.

OTHER SUGGESTIONS: ✔ Eat slowly in a relaxed atmosphere. ✔ Ask your doctor for an antiemetic medicine. Take it as soon as you feel nauseous. ✔ Do not lie down immediately after eating. Allow an hour or two after a meal before you go to bed – or sit up in bed. When you lie down, raise your head with a puffed up pillow, put a pillow in the hollow of your back and one under your knees. ✔ If you are receiving chemotherapy, eat a small meal at least two hours before treatment. You should also save your favourite foods for when you are feeling well so that your mind does not learn to link your favourite foods with nausea. Know the specific dietary instructions for all medications. ✔ Take most medications with food unless specifically instructed to do otherwise. Food helps to stimulate the digestive enzymes that are needed to digest medicine. ✔ Try some deep breathing.

SUGGESTIONS FOR THAT FUNNY TUMMY ✔ Eat smaller meals more often. ✔ Avoid foods that are hard to digest, like fat and milk. ✔ Eat dry and liquid foods separately. Drink liquids between meals, about one hour after you have eaten. ✔ Use fresh herbs to add flavour rather than using strong spices like curry and chillies. ✔ Fruit like papaya help to stimulate digestive enzymes. ✔ Eat in a relaxed environment. Stress uses up nutrients stored in the body and prevents the body from absorbing the nutrients in food. ✔ With any stomach complaint, it is important to experiment. Try different foods to find out which agree with you and which do not. Cut out different foods if you suspect they are making your condition worse. ✔ Use your common sense and avoid foods that cause you pain, burn your throat and stomach, cause bloating or give you heartburn.

Diarrhoea WHAT TO EAT MORE OF: ✔ Lots of fluids. Sip a Rehydration Drink as often as possible. To make a Rehydration Drink, take one litre of water that has been boiled (use a 1 litre cold drink bottle), add 8 teaspoons of sugar, half a teaspoon of salt and one level teaspoon of bicarb. ✔ Mashed ripe banana is fantastic because banana contains a lot of potassium, which is good for fluid retention and helps stabilise digestive enzymes. ✔ Apple, pear and grape juices are the best juices for diarrhoea. ✔ Foods that contain soluble fibre will help bind fluids in the gut, such as oats, peeled and grated apple or pear, mashed ripe banana, beans and lentils (well cooked and mashed). ✔ Starchy foods like rice, oats and potatoes. ✔ It is very important to get enough plant protein in your diet.

✔ Remember that diarrhoea removes the helpful bacteria

of the gut so it is always a good idea to eat lots of fatfree yoghurt (which contains these helpful bacteria) after the diarrhoea has passed. You can also buy these bacteria in the more expensive capsule form at a pharmacy.

WHAT TO AVOID: ✘ Experiment to find out what foods make your diarrhoea worse. Cut out one type of food at a time. You may need to eat less dairy. You may want to eat les fatty foods or fewer foods high in fibre (like whole-wheat bread, brantype cold cereal, nuts, green vegetables, sweet corn, peas and the skin of fruits). ✘ Avoid foods high in fat like fried foods, margarine, butter and oils. ✘ Avoid caffeine, alcohol and sugary cold drinks. ✘ Avoid gas-forming foods such as cabbage, onions, beans and fizzy drinks. ✘ Stay away from enemas or “cleansing” medicines that increase diarrhoea.

OTHER SUGGESTIONS: ✔ Consult your doctor or clinic immediately. Diarrhoea is a serious condition that can kill if not stopped in time. ✔ When feeling ill, try drinking soup, like chicken, meat, lentil or vegetable soup. ✔ Drink rice water – the water that is left over after cooking rice. ✔ Dilute all fruit juices with water. ✔ If you are taking supplements, take a break for a while. ✔ If you have a guava tree growing nearby you can make a tea with 2-3 leaves. Take until diarrhoea goes away. Be careful not to overdo it. Too much can cause constipation.

You can also use sour fig leaves. ✔ Eat slowly and eat smaller, more frequent, meals. Large meals may stimulate bowel action too much. ✔ Try sitting quietly after a meal.

Altered taste SUGGESTIONS: ✔ Try flavouring foods with herbs such as rosemary and thyme.

Marinate your chicken, fish and other meat. ✔ Serve food at room temperature. ✔ Drink plenty of fluids. ✔ Use salty water to rinse your mouth frequently.

Fever WHAT TO EAT MORE OF: ✔ You need to replace fluids that have been lost. Make soups that are rich in protein and carbohydrates and vegetables. ✔ Raspberry juice. ✔ Tea made with apple tree bark (handful of apple tree bark, pour 2 cups of boiling water over and let cool, drink).

Bloatedness WHAT TO AVOID: ✘ Gas-forming foods, like onions, cauliflower, broccoli, cabbage, Brussels sprouts, beans, bean sprouts, fizzy carbonated drinks and beer.

OTHER SUGGESTIONS: ✔ Chew all food well. Ten times a mouthful! ✔ Try eating yoghurt before a meal. ✔ Drink fennel or aniseed tea. ✔ Separate fruit from other food by an hour. Fruit needs alkalines to digest and proteins need sulphuric acid.

These two cancel each other out and the food just rots.

Heartburn WHAT TO EAT MORE OF: ✔ Oats and ripe bananas.

WHAT TO AVOID: ✘ Greasy, fried, very spicy foods and pepper. ✘ Aspirin, alcohol, coffee, cigarettes, fizzy carbonated drinks, peppermints and chocolates.

OTHER SUGGESTIONS: ✘ Eat starch and proteins at different times. ✘ Take antacid 30 minutes after eating. Bear in mind that regular use of antacid does interfere with digestion.

You could try using papaya as an antacid, or fruit salts, or bicarb. ✘ As with nausea, allow an hour or two after a meal before you go to bed. Try raising your head and supporting your back with a pillow, and placing another under your knees. ✘ Eat small, regular meals. ✘ Origanum tea with a sprinkle of nutmeg.

Loss of appetite SUGGESTIONS: ✔ It may be easier to slowly sip a drink that has been made ✔ ✔ ✔ ✔ ✔ ✔ ✔

in a blender rather than eat a very chewy meal. Try mixing some fruit with yoghurt.

Make eating fun. Get together with other people for an event that sparks an interest in eating.

Light exercise, like walking, increases the appetite.

When you do feel like cooking, prepare a large amount and freeze some for those times when you do not feel like cooking.

Choose food which you enjoy because you are likely to eat more. But also try to eat foods which give you energy.

Eat as many different foods as possible.

Keep a healthy supply of snacks.

Crush one handful each of papaya and dandelion leaves and pour 3 cups of boiling water over, allow to cool, drink a cup 3 times a day to stimulate appetite.

Constipation WHAT TO EAT MORE OF: ✔ Eat more soluble fibre like oats or mabele. ✔ Gradually increase high fibre foods like bran-type cold cereal, green vegetables, sweetcorn, peas as well as fruits and raw vegetables with their skins. It has been suggested that these insoluble fibres can sometimes cause bowel irritation and aggravate colitis, so increase them gradually. ✔ Drink plenty of fluids between meals (one-half hour before meals and two hours after eating). ✔ Add the juice of an Aloe leaf to a cup of boiled water at bed time. ✔ Eat dried prunes.

WHAT TO AVOID: ✘ Refined and processed foods. ✘ Enemas, laxatives or “cleansing” treatments that cause diarrhoea.

OTHER SUGGESTIONS: ✔ Get regular exercise

Thrush (Candida) WHAT TO EAT MORE OF: ✔ Eat more proteins. ✔ Eat more vegetables.

✔ ✔ ✔ ✔ ✔

Beans and grains.

Garlic.

Eat cold or room temperature foods.

Vitamin E. Foods that are easy to eat because they are soft and moist, like mashed potatoes, scrambled eggs, blended smoothies, ripe fruits (especially bananas, peaches and pears). Cook all foods until soft.

WHAT TO AVOID: ✘ Candida thrives on sugar, so reduce sugar. ✘ It is also a good idea to reduce carbohydrates and fruit.

Avoid junk food, which consists of simple carbohydrates that convert quickly to sugar. ✘ Pineapple. ✘ Alcohol and yeasty foods like bread, and hard cheeses, because they help the growth of Candida. ✘ Spicy, hard (chips, nuts, seeds, raw vegetables), salty, sticky (peanut butter, sweets) and sour foods (pickles, citrus fruits and juices).

OTHER SUGGESTIONS: ✔ When oral thrush appears, there is usually a good chance that it is present in other parts of the body as well. So, you should be treating your whole system. ✔ Reduce your body’s acidity. ✔ When trying to cope with mouth and throat infections like thrush, it is important to get help as soon as possible.

Treatment for thrush is available from your clinic. ✔ If you are finding it hard to swallow, use a straw. ✔ Tilt your head back to make swallowing easier. ✔ Keep your mouth clean by rinsing with salty water. ✔ Drink plenty of fluids. ✔ Make a tea from a teaspoon of ground cloves. Allow to cool and then sip. ✔ Chew grape fruit pips to kill Candida spores.

Other dietary considerations include avoiding all simple sugars, dairy (except if cultured), alcohol, hard cheeses, dried fruits, melons, peanuts and all suspected food allergens as all these will support Candida.

Fatigue WHAT TO EAT MORE OF: ✔ Eat adequate calories and protein.

WHAT TO AVOID: ✘ Energy-robbers like sugar, alcohol, fats, white flour products and highly processed foods. ✘ Large amounts of caffeine that may interfere with sleep patterns and increase fatigue when the caffeine wears off.

OTHER SUGGESTIONS: ✔ If you are experiencing unusual fatigue see your doctor or clinic. ✔ Eat smaller meals as often as every 1 or 2 hrs. ✔ Focus on your favourite foods and, when you cook, make extra so that you can freeze some for an easy meal later. ✔ Snack, snack, snack. Hard boiled eggs (kept in the fridge), dried fruit and nuts are great. ✔ Maintain muscle weight. ✔ Supplement with B vitamin complex. If you can afford it, other useful supplements are co-enzyme Q10, selenium, cysteine and glutamine. ✔ Get support for emotional issues through therapy, support groups, or friends. ✔ When possible, eat together with friends. ✔ Practise deep breathing exercises to maximize oxygen intake. ✔ Exercise.

Nutrition information for this article provided with kind permission from Taste for Life

Southern African Sexual Health Association www.sexualhealth.co.za

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CD4 magazine Editor Yngve Sjolund Contributors Doctor Eric S. Freedland, MD Dawie Nel and the staff at OUT Lesbian/Gay/Bisexual/ Transgender(LGBT) Well-being.

Eric M. Richardson and Margaret Roper Thabo Nhlapo Leigh Maftipa Boitumelo Sekhu Prudence Mhaula Lisa Dewberry Yngve Sjolund Dr Anton Janse van Rensburg SASHA Editorial Board Project Editor: Dr Ezio Baraldi Sub-editor: Christa Coetzee Reviewers: Dr Esther Sapire, Dr Prithy Ramlachan, Rory du Plessis, Christa Coetzee, Dr Ezio Baraldi, Ruthie Loubser, Ronald Adinall Design, layout and graphics, Printing CPD Printers Hatfield www.cpdprint.co.za Tel: +27 (0)12 342 1978

A BIG THANK-YOU!

DISCLAIMER The opinions printed in this magazine are those of the contributors. While every effort is made to ensure the accuracy of information contained in this magazine, the editor and the Southern African Sexual Health Association, its directors and members do not endorse or are liable for the information contained in CD4 magazine.

You’re going to be dealing with HIV for the rest of your life. Learning more about all your treatment options can help you life a healthier, longer life. This magazine is intended to enhance your relationship with your doctor - not replace it. Medical treatments and products should always be discussed with a licensed physician who has experience treating HIV and AIDS. COPYRIGHT CD4 magazine is published by Yngve Sjolund for the benefit of people living with HIV, their friends and families, and their healthcare providers. Non-commercial reproduc-tion of content is encouraged, provided that appropriate credit is given.

CIRCULATION 5,000 Free copies distributed to clinics, hospitals and VCT sites that offer HIV / AIDS treatment and care in Gauteng Province, South Africa. Additional copies printed as funds permit, and distributed to health care professionals in South Africa.

Publication of CD4 Magazine is made possible by a generous grant from the Ford Foundation Please contact CD4 magazine: Project Editor: Dr Ezio Baraldi Tel: +27 (0)12. 342 - 5704 admin@cd4.sexualhealth.co.za

OUT LGBT Wellness, Pretoria Tel: +27 (0)12 344 5108, www.out.org.za Interactive Themba Theatre 58 Jorissen Street, Braamfontein Box 32705, Braamfontein, 2017, South Africa Tel: +27 (0)11 403 - 7222 / +27 (0)11 403 – 9367 bookings@themba.org.za

CD4 Editor: Yngve Sjolund Cell: +27 (0)84. 581 – 0320, Fax: +27 (0)86. 653 - 8204 editor@cd4.sexualhealth.co.za Circulation and Advertising: Rory du Plessis Tel: +27 (0)82. 468 - 3780 info@CD4.sexualhealth.co.za

Eric Richardson, Thabo Nhlapo, Leigh Maftipa, boitumelo Sekhu and Prudence Mhaula.

Cover image: Courtesy of THEMBA INTERACTIVE THEATRE TASTE FOR LIFE © 2005 (HIV & Nutrition) - Published

by MEGA, the Medicinal & Edible Gardens Association PO Box 1178, Parklands, Gauteng - 2121, South Africa.

Tel/Fax: +27 (0)11 477-3236, talfryn@mega.org.za THRIVE magazine published by AIDS Healthcare Foundation 6255 W. Sunset Blvd., 21st Floor, Los Angeles, CA 90028, thrive@aidshealth.org page 4

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Southern African Sexual Health Association (SASHA) www.sexualhealth.co.za Confidential Telephone Helpline +27 086 100 262

Southern African Sexual Health Association Helpline +27 086 100 262

From the Editor

The concept of ‘diversity’ in South Africa today encompasses many things: race, age, religion, ethnicity, gender, and sexual orientation … even HIV-status! And wherever there is difference, we must remember that we - as a rainbow-nation – are united in our diversity.

Many South Africans living with HIV still suffer discrimination. Fortunately, we have laws and a Constitution that ensures equality and protects minorities and diverse groups. Being ‘different’ and labelled as gay or lesbian still comes at a cost, and gay men and lesbian women frequently encounter fear, harassment and discrimination on the grounds that they could be HIV-positive - or have aids. Even though gay men were the first to develop HIV-related illnesses in large numbers in the West, the worldwide reality today confirms that no-one is immune. HIV/aids now predominantly affect heterosexual people - and specifically young Black women here in South Africa.

We can all play a role in transforming South Africa into a non-racial, non-sexist, HEALTHY and prosperous country! As a nation of diverse cultures and beliefs we need to support each other – especially those affected or infected with HIV. Our young people need guidance in the development of new values and attitudes for healthier living. As a young democracy we also need to engage with each other to come to an understanding on how to deal with the very real reality – and challenges - of HIV/aids.

Being healthy is not just about avoiding illness. Being healthy means functioning at your best and most satisfying – physically, emotionally and intellectually. There are a few simple guidelines everyone can apply to achieve this: GET TESTED FOR HIV AND KNOW YOUR STATUS If you discover that you are HIV-positive, find a doctor or health care practitioner who is an expert on HIV as soon as possible. Ask for a referral to someone whom you can trust. Speak honestly to them about your lifestyle and sexuality and then make it a priority to map out a treatment strategy that will ensure a long, healthy life – for you!

If you feel that you are different and would like to share your story - or have tips for healthier living for the readers of CD4 - please contact me at: editor@cd4.co.za.

Be safe, stay happy and be healthy!

Yngve Sjolund

W

e all know that living with HIV is not a death sentence - and that HIV is not the end of the world.

In our article Making a life change (page 6) we meet Helga Rabotapi. Helga is a 36 year old mother who has been living with HIV for the past five years. She wanted to share her story with us – on how she felt angry, hurt and disappointed when she first realised she was HIV-positive. She had many questions and wanted to find out “why?” She was scared and wanted to know what went wrong. Helga thought that she was “going to die” – but now she says optimistically: “I am not doing things carelessly now. I am living positively and taking care of myself”. Helga advises those infected with the disease to join a support group once they have been diagnosed HIV-positive – “because the support group will be there for you. Lets live, support and take care of those with HIV/aids. We need to stop discriminating against those infected and need to be there for each other!”

It has been said, “Let your food be your medicine and your medicine your food” - and in this issue we tackle the importance of good nutrition. In The relationship between HIV & nutrition (page 8) you can learn some of the basic information about deficiencies - and supplements that you need - when you first test positive for HIV. Always discuss your Medical issues and HIV-treatment with a licensed physician who has experience treating HIV and aids!

In this Issue

The worst thing we can do to our bodies when we are living with HIV is abusing drugs and alcohol. In Substance use and HIV (page 10) we take a look at the adverse effects of illegal street drugs and alcohol abuse and how they affect our ARV regimens and over-all wellness.

Young lesbian, gay, bisexual, or transgendered (LGBT) people face particular challenges. They may not have easy access to information about their sexuality, and at an age where traditional values and acceptance is important, they may try to conceal their true sexuality from family and friends to avoid rejection. All these factors do increase their vulnerability for contracting HIV. In Understanding ‘diversity & gender’ by Eric M. Richardson and Margaret Roper (page 26) we learn that organisations involved in HIV/aids education and support should not neglect the unique needs of LGBT people - or people involved in same-sex relationships.

Advances in the treatment of HIV in recent years have led HIV/aids organisations to focus on eradicating stigma and discrimination, as well as promoting safer sex practices and HIV testing. There has also been a growing awareness amongst researchers in HIV/aids prevention and education around gender fairness and equality, but organisations involved in HIV health work must consider the feelings, relationship behaviour, roles, social norms, and the use of condoms of LGBT people.

Southern African Sexual Health Association www.sexualhealth.co.za

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Positive Profile

Making a life change

By Lisa Dewberry

Helga is a mother of two and has been living with HIV for five years now - she tested positive on 31 October 2003 when she was 32 years old.

“

“

I am not doing things

carelessly now. I am living positively and taking care of myself - Helga Rabotapi

H

elga Rabotapi is a 36 year old mother, who - just like any other young mother - likes to read, watch television, go to church and have fun with friends.

she didn’t know what killed her son. She says that his family spoke about it with her but they didn’t go straight to the point.

After hearing rumours from people at the funeral of her boyfriend that he had possibly contracted the disease, Helga decided to go for an HIV test at the Pholosong Hospital in Tsakane. He had died at the age of 33 years old from Pulmonary Tuberculosis in May of 2003. He had been continually sick - at and off work - and started becoming seriously ill in 2002.

“I do remember a time when he approached the subject once with me - in a joking manner and he said to me: ‘What will you do if I had to get tested for HIV/Aids and the results came out positive?’ My response was: ‘That will be the end of us.’ I would have definitely responded in a different way if I knew he had been serious, and I think because of my response he might have chosen not to say anything because he didn’t want to lose me,” says Helga.

Helga says she received her positive test results from a counsellor at the hospital within just 15 minutes of going to the hospital to get her test done. She also received both pre-counselling and post-counselling on the day.

“I felt angry, hurt and disappointed when I realised I was HIV-positive. I wanted to ask questions and wanted to find out why my boyfriend had done this … but I couldn’t because he was already dead. I was scared and wanted to know what went wrong. I thought I was going to die” says Helga. She couldn’t really discuss anything with her late boyfriends’ parents because his mother would just say that page 6

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FAMILY BACKGROUND Helga was born in Brakpan Old Location and moved with her mom to Tsakane (near Springs) when she was nine years old. For the past 27 years of her life she has stayed in Tsakane, where she matriculated from Tholulwazi Secondary School in 1991. Helga worked briefly as an agent for a funeral undertaking in 1999 but was retrenched after just three months. Since then she has not been able to obtain a stable job.

Southern African Sexual Health Association Helpline +27 086 100 262

Positive Profile Helga also has a sister of 50 years old staying in Thokoza and she lost her younger sister to HIV/Aids in February 2005 when she was only 25 years old. “I tried to be there for her,” she says.

Helga has two children, a girl of 16 years old and a boy of 12 years old. She says she broke up with the father of her daughter when she was two years old. Her son was fathered by her deceased boyfriend, and both her children have tested HIV-negative.

“Both children know that their mom is HIV- positive. My daughter found out because of a conversation I created with her one day after a television programme had been shown on TV about HIV/Aids and I asked her what she would do if she found out someone in her family had HIV. She said to me that she would accept it because it made no difference to her. Her son on the other hand has only been told indirectly because he withdraws when he gets hurt and I still want to protect him,” says Helga.

Helga says she does not know for how long she has been living with the disease but she does know that when she was pregnant with her son she tested negative for the disease.

“Facing my children about my disease was one of the most difficult challenges for me, because at first I thought death.

But this whole experience has made me stronger. I have been given a purpose from God, and if I was not brave I would be dead. This was a wake up call for me to make others aware to take care of themselves” says Helga.

When she told her mother that she was HIV- positive, her mother was very supportive. Helga says she has also received a great deal of support from the Methodist Church in Tsakane and some of her friends were supportive, while others were not and spoke behind her back.

GETTING ACTIVELY INVOLVED After being diagnosed with HIV in 2004, Helga says she became a member of the Treatment Action Campaign (TAC), a support group in Braamfontein for those infected and affected by HIV/Aids. The TAC is a door to door campaign educating people about HIV/Aids, Sexually Transmitted Diseases and Tuberculosis and fights for the rights of those affected by HIV to get access to treatment. She attends this group the second Friday of each month.

Helga has also joined the ‘Siyingobile For Sure Support Group’ at the Pholosong Hospital where she bakes cakes everyday and sells them to patients and staff at the hospital.

Twice a month on Fridays the group sits down to discuss their problems. They are also given advice on how to live with HIV. MAKING A LIFE CHANGE Since Helga discovered her status she says she has become more aware of things. “I am not doing things carelessly now. I am living positively and taking care of myself. This was a wake-up call for me. I now wake up in the mornings

and walk to the hospital instead of taking a taxi everywhere like I used to. Now I will only take taxis if it is cold or raining” she says.

Helga says she now does aerobics when she feels like it during the day and tries to relax as much as possible because she must not stress herself as her CD4 count will decrease. “I used to go a week at a time eating junk food, but now I have started eating lots of fruits and vegetables and drinking water and I now prefer juice to fizzy drinks” she says.

Helga has been taking anti-retrovirals (ARVs) as well as vitamins for two years now which have helped her a great deal. When she started with the anti-retrovirals her CD4 count was below 200, but now it is above 500.

“I still enjoy watching television, reading magazines and books, going to church and listening to gospel music which uplifts me. I am very social and enjoy being with my friends. My closest friends are part of the volunteer group at the hospital,” she says. “I would also like to get a degree or diploma in computers so that I can be my own boss and start my own business in computers such as a computer centre where I can teach children how to use computers,” she adds.

Helga currently lives with her grandparents in Tsakane and survives off a disability grant. She now wants to become a counsellor to counsel other people because she says she knows where they are coming from and can share their pain.

HELGA’S ADVICE Helga says that living with HIV is not a death sentence and it is not the end of the world. “I have been living with the disease for five years now.

You should take it as a wake-up call. Don’t drink alcohol, learn to compromise with your boyfriend or girlfriend and enjoy life to fullest in the right way. You should try to open up if you are aware you have the disease because most people are too scared to come out,” she says.

Helga advises those infected with the disease to join a support group once they have been diagnosed HIV-positive - because the support group will be there for them.

“Lets live, support and take care of those with HIV/Aids. We need to stop discriminating against those infected and need to stop pointing fingers because no one knows what the future holds for them. Anyone can get the virus. Let’s be there for each other!”

Southern African Sexual Health Association www.sexualhealth.co.za

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The relationship between HIV & nutrition FROM THE MOMENT YOU ARE INFECTED WITH HIV …

• your nutritional needs change and you should be taking a closer look at how what you are eating can increase or decrease your health.

• you have greater energy needs than most other people, because your body is using up a lot of energy in its attempts to fight HIV, even if you are showing no symptoms.

• HIV infection begins causing serious nutrition deficiencies.

• HIV infection, related opportunistic infections and the side effects of medications can produce a vicious cycle of malabsorbtion and malnutrition.

• Each of these effects can be dealt with through food!

• As it has been said, “Let your food be your medicine and your medicine your food.”

DEFICIENCIES HIV infection causes specific deficiencies (A, C, E, B6 and B12, as well as zinc, iron, copper, magnesium and selenium salts). The easiest way to combat deficiencies is to eat more fresh fruit and vegetables. You can also do some research and find out which foods contain those vitamins and minerals that HIV infection depletes. Here is a list of some of them.

VITAMIN A (ALSO KNOWN AS BETA CAROTENE): liver, butter, cheese, eggs, spinach, yellow and green vegetables or fruit VITAMIN C: tomatoes, potatoes, citrus fruit, mangoes, guava, broccoli, parsley, green peppers, strawberries VITAMIN E: vegetable oils (unheated), dark green leafy vegetables, nuts VITAMIN B6: whole-wheat products, wheat bran, brewer’s yeast, liver, bananas, meats, fatty fish like sardines, potatoes, vegetables, eggs, nuts VITAMIN B12: liver, kidney, fish, meat, eggs, milk products ZINC: whole-wheat bread, eggs, beans, wholegrain cereals, rice, dark green leafy vegetables, potatoes, liver, brewer’s yeast, shellfish, meat, hard cheese, tinned fish, nuts IRON: liver, kidney, red meat, eggs COPPER: liver, shellfish, nuts, pulses (beans), cereals, meat, fish, poultry, wholewheat bread, dried fruits MANGANESE: cereals, whole-wheat bread, nuts, pulses (beans), fruit, green leafy vegetables, liver, root vegetables, meat, fish

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Southern African Sexual Health Association Helpline +27 086 100 262

MAGNESIUM: soya beans, nuts, brewer’s yeast, whole-wheat flour, whole-wheat bread, brown rice, dried peas, rye flour, seafoods, dried fruits, vegetables, meats, bananas, green leafy vegetables SELENIUM SALTS: organ meats, fish, shellfish, muscle meats, wholegrain products, cereals, dairy products, fruit, vegetables, Brazil nuts Medication also causes deficiencies as the body uses its store of nutrients to process and detoxify medication. You can choose to become more familiar with the way certain treatment programmes cause nutritional deficiencies so you know how to adapt your diet. Most TB medications, for example, cause vitamin B6 and B12 deficiencies. Other medications cause zinc, copper, calcium, magnesium and niacin (B3) deficiency. AZT requires magnesium, B6, B12 and zinc. DDI requires molybdenum, vitamin C and E. Most drugs deplete vitamin C. Bactrim depletes folates. Most sulphur based drugs cause nausea.

The body may be constantly using up nutrients to fight opportunistic infections. The body also uses up nutrients to deal with emotional stress. Cortisol is the primary hormone generated in times of stress. High levels of cortisol interfere with metabolism and can contribute to insulin resistance, fat accumulation, depression, and decreased immunity.

Chronic overeating and under-eating, as a result of anxiety, depression, isolation, and substance use, further interfere with metabolism.

MALABSORPTION AND MALNUTRITION T -cells line the stomach and digestive tract.

If these T-cells are infected with HIV, they can cause the lining of the gut to become inflamed which leads to malabsorption.

•

Malabsorption is caused by infections in the gut as well as secondary infections, like sores in the throat and mouth, preventing intake of nutrients.

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Appetite loss adds to malnutrition.

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Loss of muscle weight can significantly reduce the body’s available nutrients, because nutrients are stored in the muscles.

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Medication can also cause nausea and vomiting, negatively affecting absorption of nutrition.

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Under-nourishment eventually lowers tolerance of medication

•

Under-nourishment also leads to hormonal deficiencies.

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The body’s ability to kill infectious organisms is decreased in undernourished people.

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Under-nourished people have fewer B cells, CD4+ and CD8+ T-cell counts. T-cells that are present have a reduced capacity to fight infection.

Organs important to the functioning of the immune system, like the thymus, spleen and lymph nodes, do not function well in undernourished people.

Source: Taste for Life

Southern African Sexual Health Association www.sexualhealth.co.za

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Substance use and HIV When we think of “drugs” we tend to think of illegal substances, many of which are far less dangerous than legal ones. The truth is that any substance you put into your body alters your state of consciousness.

The decision to call some substances drugs, others food, others medicine and others poison, is usually based on cultural beliefs and values. We are all familiar with the way chocolate and coffee can alter moods. More subtle changes in consciousness sometimes go unnoticed by our abused and confused bodies.

A FEW WORDS ABOUT ALCOHOL

The first and most important thing to remember is that substance use can affect your judgement. Many of us who have HIV know how to protect ourselves, but we allow drugs, especially alcohol, to dull our judgement and lead to choices we would not have made if we were more sober. Substances like alcohol, ecstasy, amphetamines and methamphetamine, all increase the risk of unprotected sex. I have friends who have sworn love to each other under the influence of Ecstasy and lived to regret the decisions they made. Ecstasy users (when compared with non-users) also tend to have more partners, more one-night stands and more unprotected sex.

The same loss of judgement can also become a problem when you are taking ARVs. Substance use can make you forget to take your medication. Anti-HIV medications can increase the blood levels of certain substances We already know that many anti-HIV medications have negative results when combined with prescribed drugs. It is not always clear what the results will be when combined with street drugs, because street drugs are very rarely pure and are therefore difficult to study. Some anti-HIV medication actually increases the blood levels of certain mindaltering substances, like the *MDMA in Ecstasy, the **THC in marijuana / dagga, as well as LSD (acid), ketamine, amphetamines, and methamphetamines (speed, tik). This can have unexpected results and the negative side effects of these substances may be increased. One exception to this is heroin. Some anti-HIV medication might decrease levels of heroin in the blood causing users to take more and increase the risk of overdose.

Some mind-altering substances, like smoked marijuana, decrease the level of anti-HIV medication in the blood.

Some substances, like ***GHB, suppress the immune system. Others, like Poppers (amyl nitrite), actually increase |

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SUBSTANCE USE CAN LEAD TO AN OVERALL DECREASE IN HEALTH The use of substances can also lead to conditions that are not favourable in people with HIV, like memory impairment, weight loss, dehydration, the depletion of valuable nutrients, lack of sleep, depression and anxiety.

SUBSTANCE USE CAN AFFECT YOUR JUDGEMENT

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the progression of HIV itself. Some studies suggest that cocaine increases the replication of HIV.

Alcohol can cause loss of good judgement, especially with regards to protected sex and adherence to medications. Alcohol dehydrates you. You lose the water you need for health and the process of detoxification. You also put extra strain on your liver, which now has to deal with the toxins of your medication as well as the alcohol. If you are taking alcohol together with ARVs, which also stress the liver, your liver may be facing a serious and dangerous challenge. Long-term use of alcohol can also cause something called “enzyme induction” – this is when the medicines you have taken get broken down too quickly and you have levels that are too low to deal with HIV effectively. Heavy drinkers are four times less likely to achieve a low viral load with ARVs. There is some good news however! Lots of research suggests that small amounts of alcohol (especially red wine) can be beneficial.

Article provided with kind permission from Taste for Life

*MDMA, or Methylenedioxymethamphetamine, is most commonly known today by the street name Ecstasy. MDMA also falls under many other broad categories of substances, including stimulants and psychedelics. MDMA is one of the most widely used illicit drugs in the world and is taken in a variety of contexts far removed from its roots in psychotherapeutic settings. It is commonly associated with the rave culture and its related genres of music. **THC, or Tetrahydrocannabinol, is the main psychoactive substance found in the Cannabis (Dagga) plant. ***GHB, or gamma-Hydroxybutyric acid, is a naturally-occurring substance that is naturally produced in the human body’s cells and found in the central nervous system, and also produced as a result of fermentation, and so is found in small quantities in some beers and wines. It is also a neuroprotective therapeutic nutrient that is categorized as an illegal drug in a number of countries, and is also used illegally either as an intoxicant or as a date rape drug.

Definitions from: Wikipedia, the free encyclopedia

Southern African Sexual Health Association Helpline +27 086 100 262

Sister Joyce A True Inspiration

Sister Joyce is the proud founder and coordinator of the Hope Clinic support group. She is much more than a nurse. She is a healer with passion and vision. What I find most interesting about her is that she never draws attention to herself. She presents herself as an ordinary person simply trying to participate in solving problems in her community – but she is doing extraordinary things.

In a world that confronts us with so many things we cannot control we should at least take control of the things we can.Control what you put into your body.

THABA: WHY ARE SUPPORT GROUPS SO IMPORTANT? SISTER JOYCE: There are many emotional challenges to

living with HIV. Support groups link people to each other.

Without this kind of emotional support stress levels rise and people move towards illness a lot faster. Motivation is a critical part of any treatment programme. People living with HIV can become demotivated when they experience the symptoms of the virus or the side effects of ARVs. The stigma of HIV/AIDS is also still very bad and people feel isolated from their friends, their families and their communities.

Living with HIV is hard enough. Having to hide your status or become dependent on others, as often happens in later stages of HIV infection, just adds to the stress. The support group can be a life force for people living with HIV. Coming together with others to speak openly about challenges and to solve problems together is definitely motivating.

Members learn coping skills from one another. And we don’t always sit and dwell on the negatives. We are a funny bunch and we do a lot of laughing, I assure you.

THABA: HOW HAS THE GARDEN HELPED? SISTER JOYCE: Our garden has two purposes: It is the link

to the nutritional therapy that is so important for people with HIV, and it has also helped members of the group to concentrate on healing rather than helplessness. While we grow the garden it is also growing us from being passive victims to active participants in our own health.

Now, at least three times a day, every time someone makes a choice about what they are going to eat they act deliberately and remind themselves of the amount of control they have in their lives. It hasn’t been an easy process. Many people with HIV have already lost faith in healing and have the eating habits of a lifetime that don’t change easily. They need to have their faith in healing restored.

THABA: I WAS SURPRISED TO SEE A TRADITIONAL HEALER IN YOUR GROUP? I THOUGHT WESTERN MEDICINE WAS IN CONFLICT WITH TRADITIONAL HEALING? SISTER JOYCE: Unfortunately this has been the perception for some time, but it is changing, particularly around HIV/ AIDS. Many, many people in Africa consult traditional healers and it is not surprising that traditional healers are becoming interested to learn more about HIV. Just like western doctors, traditional healers are trusted as experts and the people who go to them take their advice seriously.

Many traditional healers use herbs and concoctions that improve the health of people with HIV.

When people tell me they are receiving herbs from a traditional healer I do not discourage them. Healers use medicinal plants and so do complementary health practitioners like naturopaths. Many western medicines come from these plants. There are many medicinal plants that can be used for treating HIV and opportunistic infections. And traditional medicines are often cheaper than the western medicines that you get at the chemist. I do give advice to people who visit traditional healers because, as with western medicine, there are treatments that can make you sicker.

I encourage people to be in control of their health, to question and to make sure they understand the treatment options and what they are putting into their bodies. I would say this goes for all people managing their health, not only those with HIV. If people with HIV are visiting traditional healers I advise them to avoid any mixture that makes them vomit or causes diarrhoea. I also offer them a liver function test to check if the herbs they are taking are toxic. Many people are not aware that some herbs are toxic and can damage rather than help the body. I also do tests to measure the effectiveness of these traditional medicines.

These include a full blood count, a CD4+ T-cell count and a viral load test. These tests are done just like the ones done for people on ARVs. It’s not guesswork. We can clearly see if the herbs are having positive or negative effects and make intelligent choices.

Southern African Sexual Health Association www.sexualhealth.co.za

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THABA: EVERYONE IN THE GROUP IS TALKING ABOUT ARVS? SISTER JOYCE: Yes. Almost everybody is putting their hopes on antiretrovirals. ARVs are the best way we have of controlling HIV infection. They inspire a lot of hope and we are excited about the roll-out that is going on. Combined with the nutrition therapy that we promote, we think ARVs can make a real difference to people living with the virus.

We do have a problem with theft at our clinic. Medicines get stolen by people who want to get high.

Some people will try anything. They also stole the fridge we need to keep the ARVs in. Our worry is that the ARVs could end up in the wrong hands. It is a serious problem because supplies of these drugs are limited and we have many people who are in need. We need to get additional security.

Being healthy is not just about avoiding illness.

Being healthy means functioning at your best and most satisfying – physically, emotionally and intellectually. To achieve this there are a few simple nutrition principles everyone can apply.

with HIV to maintain adherence by making their medicine schedules as simple as possible. Side effects often make people stop, so we teach them how to use food to help prevent or treat side effects, and how to use food to detoxify the medication. We also encourage them to get treatment for any infections or other problems as quickly as possible.

Wherever possible we also try to involve a support network of family and friends.

WHAT IS A HEALTHY DIET?

A healthy diet is not just about maintaining a healthy weight.

A healthy diet is a well worked out plan that makes sure you get all the nutrition you need to function at your best... ... strengthening your immune system, ... adding some extra VA VA VOOM to your sex life, ... maintaining your energy levels, ... improving concentration, ... dealing with the symptoms of illnesses, ... putting you on an emotional high.

Food can do all this and more...

Source: Taste for Life

THABA: WHENEVER I READ ABOUT ARVS I HEAR ABOUT ‘ADHERENCE.’ WHAT DOES THIS MEAN AND WHY IS IT IMPORTANT? SISTER JOYCE: If a person taking ARVs does not take them

as directed, if they forget to take them at the right time or with the correct food, even just a few times, the HIV in that person’s blood has the chance to learn how to change itself and resist the ARV. The ARV will then no longer be effective against the HIV. When the HIV becomes resistant to more and more drugs the treatment options become fewer. For this reason it is very important to take the medication as directed and not to stop unless a health care provider tells you to. We call this ‘adherence’ and it is a critical part of ARV treatment.

Skipping medication also allows HIV to reproduce more quickly and increase the viral load. We try to help people page 12

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Southern African Sexual Health Association Helpline +27 086 100 262

Key nutrition principles YOUR GUIDE TO A HEALTHY DIET A healthy diet can help you function at your best, not only now, but for many decades to come. Most of the common diseases of old age are the result of lifestyle choices not the result of growing old. What you eat now will create your future many years from now!

A HEALTHY DIET IS USUALLY CONSIDERED TO CONTAIN:

Proteins – that build your body and repair tissue.

Carbohydrates – that give you energy.

Fruits and vegetables – that detoxify the body, boost your immune system and assist in healing.

Fats and oils – that also provides energy, keeps up your heat, are important for communication between cells, improve your ability to think clearly, combat stress, improve sexual responses and also have important anti-inflammatory functions.

Water – that detoxifies the body, carries nutrients to cells, gives shape and form to cells, regulates body temperature and maintains peak physical performance.

Here are some core principles that you can try using as a guide to a healthy diet: 1. EAT A WIDE DIVERSITY OF FOODS: For most people, this means eating more fresh fruits and vegetables – and herbs! Eating a diversity of foods also means cutting down on those things you eat a lot of and trying new things you have never tasted before. If you eat a lot of refined carbohydrates like white mielie meal, try the healthier less refined carbohydrates like millet and sorghum. If you see a vegetable or fruit you’ve never tried before, get some advice on how to prepare it and try it for yourself.

2. EAT FOODS AS CLOSE TO THEIR NATURAL STATE AS POSSIBLE: The closer they are to their natural state, the more nutrients they have. We are surrounded by products that are far from their natural state. Shopping for healthy foods can be an effort. Read the labels of the foods you buy and try to reduce the number of foods that contain artificial colouring and artificial flavouring.

Also reduce foods that are highly processed and refined.

These are foods that have had to go through many different processes before they get to you. Examples of refined foods are white bread, white sugar and white pap. Eat whole grain foods instead of refined foods. Reduce foods that have added preservatives.

3. DRINK LOTS OF WATER: 60% of your body consists of water. All metabolic processes (see box below) take place in the water that is in your body.

You should pay attention to your thirst and not let your body dehydrate. By the time you feel your lips are dry you are already at least 5% dehydrated. A loss of just 5% of your body water results in a 30% decrease in work performance.

You know you are dehydrated when your urine is a dark colour. As you drink more water it will get lighter in colour.

You need about one glass of water a day for every 10kg of body weight. Remember to drink a lot more after you have exercised. It is best to drink most of your liquids between meals, not during meals. Drinking water is the most effective way to get rid of the unwanted “toxic” chemicals in your body. This is what some people call “detoxing.” If you are drinking river water or rain water you must boil it before drinking it. South African tap water is very safe, but many people with HIV still choose to boil. Bottled water may look sexy, but if you really want to avoid tap water you should rather filter your own.

4. REDUCE ALL ADDICTIVE SUBSTANCES: When most people think of addictive substances, they think of illegal drugs. There are however many other legal addictive substances. Sugar, alcohol, tobacco, coffee and cola flavoured drinks are just some examples. They stress the liver, keeping it too busy to do its important job of helping process other nutrients. Reducing all of these addictive substances improves most people’s health significantly. Even moderate levels of refined sugar can reduce your immune response significantly.

5. EXPERIMENT: Every person’s body has different needs, and every person has to experiment a little to find out what works best for them. Start showing more of an interest in nutrition and start becoming more aware of how your own body and emotions and thoughts are affected by different foodstuffs and substances. You could, for example, start experimenting with eating more herbs and spices. Add some fennel to steamed fish. Herbs have high nutritional value. Add some cayenne pepper to your food. It stimulates immune responses and is thought to increase the body temperature sufficiently to make it unwelcoming to foreign organisms.

You could also experiment with reducing your intake of dangerous substances like sugar and alcohol.

Metabolism is the chemical process in which complex substances get broken down in the body so that their parts can be used for energy, growth, and healing. We speak of these processes as metabolic processes. All metabolic processes take place in the water that is in your body.

Source: Taste for Life

Southern African Sexual Health Association www.sexualhealth.co.za

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Questions to ask your health care provider CD4 MAGAZINE

This magazine is intended to enhance your relationship with your doctor - not replace it! Medical treatments and products should always be discussed with a licensed physician who has experience treating HIV and AIDS! Nonhlanhla (from Taste for Life) works with a lot of people who are HIV positive, and suggests:

“

You need to find a doctor or health care practitioner you can trust. That person needs to be an expert on HIV or at least have access to people who are experts.

You must be able to speak honestly to your health care provider about lifestyle, treatment strategy … pretty much everything that affects your life

“

Here is a list of questions to ask your health care provider about any anti-HIV medications you receive:

✔ What are the side effects of this medicine? ✔How can I reduce the side-effects of this medicine? ✔ Are there foods that can help while taking this medicine? ✔ Are there foods that I should avoid or reduce? ✔ How should I time my meals and taking my medicine? ✔ Are there any other drugs that I should avoid when taking this medicine? ✔ What should I do if I experience problems?

If your health care provider does not know the answers to these questions ask them to find out. page 14

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Southern African Sexual Health Association Helpline +27 086 100 262

Managing the side effects of

HIV therapy:

KNOW YOUR OPTIONS!

N

ot that long ago, if you didn’t like the side effects of your HIV medications, the best advice anyone could give you was: grin and bear it.

If you are a long-term HIV survivor and you’ve already “cycled through” most of the available HIV drugs, you may have to live with whatever medications are still working for you. But if you are relatively newly diagnosed, you may not have to put up with unpleasant side effects. You have a choice.

We talked about HIV drug side effects with two experts who both agreed that we have come a long way since the early days of HIV therapy.

“Let’s look at the big picture,” Dr. Bischofberger said. “Ten years ago when we talked about the side effects of HIV medications, we were talking about peripheral neuropathy, pancreatitis-really serious things that were life threatening, that kept people from working and caused pain. And you had to live with those side effects. Now we’re talking about much more subtle things, and, now you have the option of changing medications.”

“There were lots of issues with the early drugs,” Dr. Shaefer added. “Going all the way back to the first days of HIV therapy with AZT (also known as Retrovir or zidovudine), when it first came out, it was very difficult for people. It had to be taken every four hours, and it caused nausea. But there was nothing else. When you’re faced with a death sentence, you’ll get up in the middle of the night to take something that makes you nauseated. Now you don’t have to.”

Since the discovery of AZT, there has been a steady stream of new HIV medications. But at first the focus was just on keeping people alive.

“Crixivan (indinavir) was an important drug when it came along,” Dr. Shaefer notes. “It was a key to HAART (Highly Active Anti-Retroviral Therapy). It resulted in an incredibly steep drop in mortality (deaths?), which was great! But from a side effects standpoint, it was a nightmare. People got kidney stones, dry skin, brittle nails. It kept people alive, but it wasn’t optimal.”

“There’s been a steady progression,” Dr. Shaefer says. “First we come up with a therapy that keeps people alive. We get it on the market as quickly as we can, because lives are at stake. Then we see if we can make it better. That’s been the history of HIV therapy-and the drugs have gotten better.”

As a specific example, Dr. Shaefer points to one of the early protease inhibitors, Agenerase (amprenavir).

“When it first came out, the dosing of Agenerase was eight big capsules full of what was essentially castor oil, twice a day. The side effects were diarrhea and gastrointestinal upsets, and they were pretty bad.”

“Then we discovered that Norvir (ritonavir) boosts the levels of other protease inhibitors in the blood. So we were able to give Agenerase as just four capsules with one capsule of Norvir twice a day, which was better.”

“Then we came up with a drug called Lexiva (fosamprenavir) which is a “prodrug” of Agenerase. Basically, it turns into Agenerase in your body. The huge advantage is in the dosing-just two pills twice a day, or two pills plus two capsules of Norvir once a day. And it is much, much easier to tolerate.”

“Now we’ve done additional studies, and we just got approval from the FDA (Food and Drug Administration) for once-a-day dosing of Lexiva with two pills plus just one capsule of Norvir. So the dosing of amprenavir has gone from eight huge capsules twice a day to just three pills once a day. A big improvement.”

Not so long ago, doctors were very reluctant to let their HIV patients switch from one drug regimen to another, because there were so few effective medications available to choose from. But now, switching drug regimens to reduce side effects is relatively common, even when the patient’s current regimen is keeping their viral load undetectable.

In fact, a recent study in England studied the effects of switching people who were doing well on a combination of Combivir (lamivudine/zidovudine) and Sustiva (efavirenz) to a regimen consisting of Truvada (emtricitabine/ tenofovir) and Sustiva.

After 48 weeks, patients in both the Combivir and Truvada arms of the study were still doing well in terms of keeping their virus suppressed. But the patients taking Truvada had less of a tendency to be anaemic, more limb fat, lower cholesterol levels, and lower triglycerides.

“For me, scientifically, the reversal of fat loss in the arms was the most interesting result of the study,” said Dr. Bischofberger. “At the beginning of the study, these folks had fat loss in their arms caused by the AZT in Combivir. Those who continued on Combivir continued to lose fat in their arms. But those who switched to Truvada gained approximately 200 grams of fat, as measured by DEXA scans.

This is important, because we already knew that AZT could cause lipoatrophy. But we didn’t know if it was reversible.

Now we know it can be reversed.”

Southern African Sexual Health Association www.sexualhealth.co.za

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If you’re unhappy with the side effects of the HIV drugs you’re taking, what should you do?

“First, keep taking your drugs, even if you don’t like the side effects, until you speak to your doctor or your pharmacist,” says Dr. Shaefer. “If you stop taking your drugs - even if you only stop taking one particular drug that’s causing you problems - you’re setting the stage for developing drug resistance. So speak to someone as soon as you can, but keep taking all your medications in the meantime.”

“People trust their doctors and they don’t like to complain,” Dr. Shafer says. “So they take their drugs until the side effects get so bad that they stop. We don’t want to see anyone doing that. Speak up before it gets to that point! If you’re

uncomfortable talking with your doctor, talk with your pharmacist instead. Very often your pharmacist is more available than your doctor, and sometimes they can intercede with your doctor for you.”

“There are lots of good HIV medications to choose from today,” Dr. Shaefer says. “Even early on, you can change out a drug and still be on a very effective regimen. So talk.

Tell your medical team what you’re experiencing, and work with them to develop a regimen you can tolerate.”

Adapted from an article for Positive! Magazine, by two HIV experts: Mark Shaefer, PharmD., Group Director for HIV Clinical Research at GlaxoSmithKline; and Norbert Bischofberger, PhD., Executive Vice President, Research & Development/Chief Scientific Officer of Gilead Sciences, Inc Copyright 2008, Positive Health Publications, Inc.

The relationship between nutrition and ARV’s Perhaps most important of all – nutrition appropriate to HIV infection may help to significantly delay the point at which a person has to start taking ART’s.

What is the role that nutrition can play if you are taking antiretrovirals or other anti-HIV medication?

ARV’s are only effective in people who are eating regularly and eating the right foods. If a person is not eating properly and is experiencing malnutrition ARV’s can be dangerous.

You need to ask your health care provider about the relationship between what you eat and the medications you have been given.

Certain nutritional strategies that are being promoted as being useful to HIV positive people in South Africa, like eating garlic, may increase gastro-intestinal side effects of certain ARV’s. Other examples: St John’s Wort, often used as an antidepressant, can reduce the effectiveness of certain ARV’s. Grapefruit also interferes with the absorption of certain ARV’s.

So make sure you know what to avoid. If in doubt consult a doctor who is experienced at dealing with HIV. While many traditional medicines have great value for people with HIV, some should be avoided when you are taking ARVs. African potato and the cancer bush need to be avoided because they seem to interfere with the action of ARVs. When you visit your doctor or clinic, do not wait for them to ask whether you are taking traditional medicines. Tell them which traditional medicines you are using so they can help you plan the best treatment and nutrition strategy possible.

Some of the side effects of medication like nausea and loss of appetite, not only make it difficult to get enough nutrients into the body; they also make it hard for people to keep taking those medications.

by using particular food and medicinal plants to reduce medication side effects, improve the appetite and increase valuable nutrient intakes. Except where indicated, take your medication together with food so that you can reduce the gastro-intestinal side effects.

A recommended practice is that your doctor or clinic draws up a customised food and drug timetable. Check the list below to see what food combinations are best with the different antiretrovirals. Share this list with your health care provider.

ARVs themselves cause toxic side effects that can lead to liver problems. These can be significantly reduced by eating foods that assist in detoxifying the effects of medication. In this regard drinking sufficient water and eating lots of fruits and vegetables is vital. Dandelion root is great for helping to detoxify the liver. Try boiling some dandelion root in water and drinking it as a tea.

ARV’s commonly cause a dangerous rise in cholesterol (lipodystrophy*), an increase in blood sugar almost like diabetes (ARVs affect glucose metabolism and cause insulin resistance). The most important nutritional advice to people using antiretrovirals is to cut down on foods that contain refined sugar and animal fats.

Increase your intake of soluble fibre (beans, most fruits and vegetables, nuts and seeds, whole grains, especially oat bran, barley, sorghum and brown rice) to reduce cholesterol levels.

Lower your intake of saturated animal fats and hydrogenated fat (margarine, processed foods, and fried foods).

Increase your intake of healthy fats, like the Omega-3s (oily fish) and monounsaturated fats (olives, olive oil, canola oil, sunflower seeds, avocados and macadamia nuts).

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Southern African Sexual Health Association Helpline +27 086 100 262

Like most medications ARV’s use up nutrients (especially vitamin C) in the process of being metabolised and give rise to certain nutrition deficiencies. These deficiencies can be dealt with through changes in a person’s diet. ARV’s also give rise to a decrease in bone density.

Make sure you are eating a lot of calcium (dark green vegetables, crushed sesame seeds and the soft bones of tinned pilchards).

It is advisable that people using ARVs reduce the amount of alcohol they are drinking. Alcohol dehydrates you. You lose the water you need for health and the process of detoxification. You also put extra strain on your liver, which now has to deal with the toxins of your medication as well as the alcohol. Long term use of alcohol can also cause something called “enzyme induction” – this is when the medicines you have taken get broken down too quickly and you then have levels that are too low to deal with HIV effectively. Heavy drinkers are four times less likely to achieve a low viral load on ARVs. The use of alcohol and other mind altering substances are also likely to make you fail to take your medication on time.

An important part of any effective nutrition programme is exercise. Exercise not only helps to build lean muscle and prevent wasting, it also helps with the process of detoxification. It increases the level of oxygen in the blood, gets nutrients to the cells, helps get rid of cholesterol, burns off excess adrenalin and helps treat depression. It also increases your body temperature, which helps the healing processes, and it keeps the immune system’s lymph glands working well. In people who are experiencing lipodystrophy* as a result of taking ARV’s, exercise can help to reduce triglycerides, decrease insulin resistance and decrease abdominal fat. Muscle makes more use of glucose than fat does, so the more muscle you have the more able you are to reduce your blood sugar.

When taking your ARV’s try not to anticipate negative side effects. Some people experience negative side effects simply because they believe they are inevitable. If you eat properly you will minimize the side effects.

Make use of your support group and those close to you by asking them to remind you to take your medication.

Get treatment for all side effects as soon as possible.

Perhaps most important of all – nutrition appropriate to HIV infection may help to significantly delay the point at which a person has to start taking ARVs. Remember that poor adherence to antiretroviral therapy can decrease the effectiveness of the treatment, can lead to the development of resistance to the treatment, and can limit your future treatment options. *Lipidodystophy: means disturbance of fat metabolism, or abnormal fat changes. Medical literature also refers to lipodystrophy as the “fat redistribution syndrome.”

ARVS & FOOD: GUIDELINES NRTI Zidovudine (AZT, Retrovir, ZDV): Should be taken outside of meals. If this is not possible, take with a low-fat meal. Avoid alcohol.

Lamivudine (Epivir-3TC): GI side effects are reduced when taken with meals. Avoid alcohol.

Abacavir (ABC, Ziagen): Avoid alcohol.

Didanosine (ddI, Videx): Take on empty stomach, at least 30 min. before or 2 hrs after a meal. Take it only with water. Food decreases absorption. Avoid alcohol as it increases the drug’s toxic side-effects. Avoid antacids containing magnesium & aluminum.

Stavudine (d4T, Zerit): Avoid alcohol.

Tenofovir (Viread): Take with food. A high-fat meal helps increase the concentration of the drug in the blood.

NNRTI Efavirenz (Stocrin, Sustiva-EFV): Take with low fat meal to improve tolerance. High fat meal may increase adverse side effects.

Take in the evening or at bedtime to minimize side effects. Alcohol may increase symptoms. Avoid taking St. John’s Wort.

Nevirapine (Viramune-NVP): Avoid St John’s Wort. Avoid alcohol.

PROTEASE INHIBITOR Amprenavir (Agenerase-APV): A high-fat diet can decrease absorption so avoid. Avoid grapefruit. Increase your intake of fluids. Avoid extra vitamin E supplements. Avoid St John’s Wort. Do not take antacids within one hour of taking this medicine.

Indinavir (Crixvan-IDV): Take on an empty stomach at least one hour before a low/nonfat meal. If you are taking ddI, take this medicine one hour after taking the ddI. Avoid grapefruit. Increase your intake of fluids. Avoid extra vitamin E supplements. Avoid St John’s Wort. Do not take antacids within one hour of taking this medicine.

Lopinavir-Ritonavir (Kaletra): Take with high fat food for better absorption. Store the capsules in the refrigerator. Avoid taking St. John’s Wort.

Nelfinavir (Viracept): Take with a meal or snack that includes a high protein food to increase absorption and to decrease GI side effects. Increase fluid intake. Lactose free dairy products or lactase may be needed to minimize diarrhea. Avoid acidic food or liquid.

Avoid taking St. John’s Wort.

Ritonavir (Norvir): Take within 2 hrs after a full meal with high calories and high fat food for better absorption and to decrease stomach upset. Store the capsules in the refrigerator. Avoid taking St. John’s Wort.

Saquinavir (Fortovase soft-gel, Invirase hard-gel): Take within 2 hrs after a full meal with high calorie and high fat foods for better absorption. Store the capsules in the refrigerator. Avoid alcohol usage. Avoid taking St. John’s Wort.

Invirase: Take within 2 hrs after a full meal with high calories, high fat, and high protein food for better absorption. Taking with grapefruit juice will also increase absorption. Avoid alcohol. Avoid taking St. John’s Wort.

Source: Taste for Life

Southern African Sexual Health Association www.sexualhealth.co.za

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Play it Safe!

INTERVIEW WITH ELMIE JOUBERT - NURSE AND VCT COUNSELLOR AT OUT LGBTI WELL-BEING

Elmie is the kind of person that straight away – when you meet her for the first time - makes you feel completely at ease! Her gentle manner and friendly smile allows any person to open up to her - and you can rest assured that whatever concern or private information you may share with Elmie – it will remain anonymous, confidential - and stay only between you and her.

OUT CLINIC AND WELLNESS CENTRE A friendly gay and lesbian affirming alternative

ll b W look l kh l ll at a person, combining the well-being.

We holistically physical and mental aspects of each person we see.”

The OUT Clinic and Wellness Centre was opened by Justice Edwin Cameron on 9 August 2006 and specifically caters to the needs of the LGBTI (Lesbian, Gay, Bisexual, Transgender and Inter-sex) communities.

YS: “Do you see mostly gay and lesbian people?”

EJ: “Only gay and lesbian people.”

Yngve Sjolund: “What made you choose a career as a HIV VCT (Voluntary Counselling and Testing) counsellor?”

Elmie Joubert: “I studied nursing and then I completed another diploma, and part of that diploma was HIV counselling.”

YS: “So you do pre- and post-counselling?”

EJ: “Yes.” YS: “What is the name of this clinic where you are working?”

EJ: “The OUT Clinic and Wellness Centre. It is called ‘wellness’ as we focus on the patient – or clients’ – total page 18

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YS: “Have you had a good success rate at your clinic?”

EJ: “We have had a very good response. We see at least 16 clients per month, but during the colder winter months numbers do go down a bit.”

YS: “When is the OUT Wellness Clinic open to the public?”

EJ: “Tuesday and Thursday evenings from 5 to 7 pm. Clients must book an appointment.”

YS: “How soon can a person get their result when you do the counselling and HIV testing here?”

EJ: “They can get it within 5 minutes.”

YS: “And then you do the post-counselling?”

EJ: “We do. If they were to test positive for HIV, we draw

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blood that we then send to the AMPATH laboratory for confirmation with a HIV Elisa test.”

YS: “How are *LGBTI clients’ needs different from straight people who go to a regular clinic?”

EJ: “This clinic was opened in August 2006 mainly for VCT and the main focus was HIV. After doing some research to determine the needs of the LGBT communities, OUT decided that they were going to expand it into a ‘Wellness Clinic’. A lot of LGBT people – due to the HIV/AIDS and gay and lesbian issues here in South Africa – felt that they did not want to go to a regular doctor as they would be likely to encounter discrimination and homophobia. Their needs are different. They don’t feel comfortable talking to a person that does not relate to the LGBTI community and its’ specific issues.”

YS: “Would you then say that some healthcare professionals – doctors, nurses – in South Africa are not sensitized to LGBTI peoples’ lifestyles or unique needs?”

EJ: “According to the clients they don’t feel comfortable in those settings and a lot of times they feel that they have been unfairly discriminated against. And they are always so happy that we offer these services when they come here!”

YS: “That’s good to hear! What kinds of discrimination do they face at some of these local Government or private Hospitals, clinics or private practices?”

EJ: “Say for example they visit a clinic to have a STI (Sexually Transmitted Infection) seen to, they will encounter comments like: ‘If you did not have this sexual orientation or these preferences, this wouldn’t have happened’. And that is why they feel uncomfortable and discriminated against.”

YS: “Do you also offer STI testing?”

EJ: “Yes, we do. We test for syphilis and gonorrhoea, as well as screening for herpes infection, Chlamydia - and we also offer cervical / vaginal PAP smear.”

YS: “For HIV and STI care, do you refer clients to a specialist physician or hospital or clinic for treatment?”

EJ: “The sisters working here at the OUT clinic can prescribe medication. So if we can, we offer treatment. We do have a referral system to some doctors and health care providers that are ‘LGBTI-friendly’. Clients who test positive for HIV can also get their ARV medication from Tshwane District / Pretoria Academic Hospital - or their nearest Government ART (Anti-retroviral Treatment) site - or if they have a medical aid, they can claim it back.”

YS: “How many incidents have you had where PEP (postexposure prophylaxis) was needed?”

EJ: “Not a lot. Since 2007 I only had two people who needed the PEP regimen. We don’t provide the medication, but refer them to access PEP within 72 hours.”

YS: “What is the ratio of gay men to lesbian women that make use of your clinic?”

EJ: “We do see more gay men. I’d say 2/3 is men and 1/3 is female.”

YS: “What are your plans for the future expansion of these clinic services?”

EJ: “We have a mobile clinic that is up and running. We usually go to Johannesburg, Mamelodi and areas in and around Pretoria. We also provide ‘VCT clinics’ at night-club venues.

For instance, last week-end we had a ‘VCT evening’ at Club Legends and next week-end we are going to Risqué in Johannesburg. In the night-club itself we give people the pre-counselling before we do the HIV rapid-test, followed by post-counselling afterwards.

I must say, it has been a great success! We usually see between 15 and 25 people in an evening that do VCT testing at those venues.”

YS: “Good - know your status! So the LGBTI community must feel that their needs are being catered for … and that you care about their health and well-being?”

EJ: “Yes. We go to them; they don’t need to come to us!”

YS: “That’s a very smart approach.

Are there any other new exciting developments here at OUT LGBTI Well-Being that we can look forward to in the future?”

EJ: “OUT is in the process of opening a Community and Wellness Centre here in Pretoria that will have a regular nurse, social workers and mental health practitioners that will be available on a more frequent basis – Monday to Thursday - during office hours in the day. We also distribute these ‘Play Safe’ packs to gay men. The pack contains condoms, lubricant and safe-sex information.

We also distribute the packs at the Shout-OUT parties for females, and they contain the female condoms with lubrication. The informational inserts show you how to use a condom and make people aware of the Play Safe campaign, our services and what we are doing here at OUT.” YS: “I see some of these services are sponsored by Standard Bank. What do you charge for a visit to this clinic?”

EJ: “Clients pay a minimum fee – at this stage it is only R10 per visit. OUT is a non-profit organization and all services are sponsored.”

Southern African Sexual Health Association www.sexualhealth.co.za

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YS: “That’s very reasonable. Do you also do the CD4 count and HIV Viral Load tests for such a nominal fee?”

EJ: “Yes, we do HIV monitoring profiles as well. This consists of a HIV Viral Load and T-cell Function (CD4 and CD8). We do not prescribe the ARVs ourselves; we refer to our local Tshwane District / Pretoria Academic Hospital.”

YS: “So you offer full testing and screening for HIV and most STI’s, like gonorrhoea, Herpes, Chlamydia as well as PAP smears?”

EJ: “Yes. What I’ve also done here before is Hepatitis-B testing. People usually only focus on HIV, but Hepatitis-B is also a virus that is sexually transmitted. And there is no cure for it.”

YS: “There is a vaccination for it, I know in the United States gay men are encouraged to get the shots.”

EJ: “Yes, mostly medical personnel are vaccinated for it in South Africa.”

YS: “Do you encourage people to get the vaccination for Hep-B?” EJ: “They can get the injection now and then again in a month and then another injection after another month.

Medical personnel should get it for the first two years and then again after five years as a booster, and then every five years after that.”

YS: “What are peoples’ emotional states when they come in for a VCT?” EJ: “People are always scared when they come in to test for HIV.”

YS: “Chronic medication?”

EJ: “Yes. But because of the way HIV is transmitted - mainly sexually, it is still stigmatized in this community. There is definitely still stigma attached to HIV.” YS: “Do you, as a nurse and healthcare professional, worry about needle-pricks? Have you been on PEP yourself?”

EJ: “I have. I think three times already. I once got placentablood in my eye from a mother that was HIV-positive. I’ve had a needle-prick injury from a client who was HIV-positive.

Because I took PEP I never contracted the HI-virus.”

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YS: “All people should know their HIV status and get onto ARV treatment as soon as possible if they test positive. Do you encounter denial?”

EJ: “What I have encountered is that some of the lesbian women think they are free from HIV-infection. Some have tested positive for HIV and STI’s as well. I’ve also had cases where one client is positive and their partner is negative, and seen how they support each other. If someone tests positive we refer them to Delene at our mental health clinic.

She also has a HIV support group.”

YS: “What other services do you offer?”

EJ: “Mental health – that’s counselling, and then Jacques, who is a psychologist, also sees clients when needed. We have HIV and STI testing and general health and wellness check-ups.”

YS: “Do you do a lot of couples counselling?”

EJ: “Yes! We see that a lot, especially in the clubs.”

YS: “Do they still believe testing positive is a death sentence?”

EJ: “Yes they do still believe HIV is a death sentence. And I always reassure them that it is not. I use the example, for instance – of people living with diabetes or high blood pressure. They also have to take medication or tablets for the rest of their lives.”

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YS: “How does that work?”

EJ: “Depending on what clinic you are using, you take one or two tablets in combination –- and you take the PEP for 30 days.”

YS: “That’s nice. Do you encourage that?”

EJ: “Yes, it’s good. But I always first ask them if they are comfortable with it, especially if you give the result to a person you need to establish that they are comfortable that their partner is present. I always ask them if they want me to give them the results in front of their partner, or in private. And they always say: ‘No, its fine, they can stay’. I actually have a great time with them in the clubs.”

YS: “So you do encourage couples counselling and couples testing together. Have you ever done a group VCT? I’ve seen that in other parts of Africa where it is very successful in creating understanding, empathy and reducing stigma.”

EJ: “I have done that before, but not here at OUT.” YS: “How does the VCT and counselling process work?”

EJ: “The first thing that we establish is confidentiality. That is what you always do first – establish that what is said is between ‘me and you’. Nobody else has access to the files, they are locked up. And then there are a few ways that you can approach it. First by asking what is their knowledge of HIV, so that you can determine what their understanding is of HIV. And from there on you can give them the information about how HIV is spread and how you can prevent it.”

YS: “And that it is a manageable chronic illness?”

EJ: “Yes. There is a check-list that we use for the pre-

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counselling to make sure that we covered everything and that we have given the client all the information. And then we also encourage them to include their family members in the process should they test positive. We always prepare them as if they are going to test positive. That way it is a lesser shock when we do give them the results. We focus on giving them more information on HIV and how they can make lifestyle changes and adapt their way of life to be healthier.

Should they test positive we tell them that they must still use condoms, because a lot of them think: ‘OK, now I’m positive and my partner is positive – we don’t need condoms anymore’ – and that is where they are actually making the mistake in exposing themselves to the risk of the virus mutating and becoming more aggressive.”

“You should be playing safe!”

YS: “It does sound like gay men are taking more responsibility.”

EJ: “Yes, I would say they definitely are taking more responsibility.”

YS: “Do you have any uplifting success stories that have made your day?”

EJ: “Oh yes, the new couples that come in – that have just started dating. They will always come for VCT before they become sexually active - or before the relationship gets too heavy. ” YS: “I always do that when I start dating someone I just met.”

EJ: “Yes, you should! You should be playing safe!”

YS: “And of course – just to know.”

EJ: “Yes. And they are usually so supportive of each other: ‘Ag bokkie, hou vas my hand’ – they’re so cute!”

YS: “So in a way HIV is an issue in the LGBTI community that creates unity and support – with fewer stigmas than we would expect?”

EJ: “Yes. I had one couple that came in and one of them was positive and the other was negative, and the love and support was very inspiring.”

YS: “Are clients who access your services here at OUT very grateful for what you are doing?

EJ: “Yes, very grateful!”

Visit OUT’s VCT Clinic and Wellness Centre for confidential consultations.

YS: “Aside from the club VCT’s, do you encourage people through the media or other means - to know their status?”

EJ: “We do advertising in the gay media and we do awareness campaigns to raise the visibility of HIV testing.

The mobile clinic goes to Johannesburg and to Mamelodi every second Saturday. We are planning to go to the Hillbrow Wellness Centre every second Saturday as well, to do VCT’s”

Call (012) 344 5108 for an appointment.

YS: “When you’ve been in the club settings and mixing with the local gay communities – have you met anybody who is out and open about their status – or noticed how people treat somebody who is open about living with HIV?” EJ: “Yes, there are a lot of people that are out and open about their HIV status. I would say its 50/50 – a lot of people still conceal the fact that they have HIV. One of the guys that tested positive at a VCT in a club avoids making eye contact with us when he sees us now. Maybe he is afraid that we will tell on him or reveal that he is HIV-positive, but we won’t do that! But a lot of the people will actually point people out to you: ‘that person is positive, that person is positive’. Not that we ask, but they will point out people that are open about living with HIV.”

• General physical examinations

YS: “And are they supportive of those people compassionate?”

EJ: “Yes, they don’t discriminate against them.”

Wellness Centre on Tuesdays and Thursdays (5pm - 7 pm) Selected primary health care services for women and men, including:

• STI testing and diagnosis • CD4 / Viral load testing • Treatment Literacy • PAP Smears • Referrals

* LGBTI: Lesbian, Gay, Bisexual, Transgender and Inter-sex

Southern African Sexual Health Association www.sexualhealth.co.za

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‘A MODERN LOVE STORY’ ‘Miss Filed’

- by Yngve Sjolund

PART FOUR

JOYCE IS MISDIAGNOSED

Previously: Jay kept his appointment at the VCT clinic and went back to get his test result, which came back negative.

The councillor, Joseph, had a frank discussion with Jay about how to stay negative, using condoms and to only practice safe sex.

He also explained how Jay should support Joyce with her chronic illness, and how ‘discordant’ couples had more challenges to face than other couples. The future for Joyce and Jay was unknown, but it seemed that they had taken the right steps to secure a strong foundation for their relationship, and they looked forward to many, many happy years together ahead of them. However, an unexpected blow took Joyce by surprise, when the new doctor at the clinic told her that she now had cancer. page 22

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J

oyce and Jay are like two lovebirds, flying free in a sky filled with possibilities. After disclosing her HIV status to Jay, and him going for a test himself, they decided to take things slowly. They would meet up for the occasional coffee date, a romantic dinner or a slow walk in the park. Every night they text messaged ‘sweet nothings’ to each other before bedtime and they even agreed that Jay could come over on the week-end. Jay would then meet Joyce’s children for the first time, and take a look at the new foundations for the room that she is building onto her house. Together, and ‘brick by brick’ they were building a secure and loving relationship, based on a solid footing of honesty and trust.

Jay is also a real gentleman and does not pressure Joyce in any way to go to bed with him. He showers her with compliments, small gifts, sweets and flowers every time he sees her. They both know that they are intelligent and independent adults with their own personal struggles, responsibilities, goals, dreams and desires in life, and that soon they will have to take the ‘next step’ in their relationship … intimacy - in the bedroom!

The way Jay has been flirting with her has made Joyce feel, after many years of being a single mother, that she was a complete woman again, confident with her body and her sexuality, and she could picture them making SAFE and sweet passionate love. Stolen kisses and long, warm embraces aroused deep feelings of love and passion between them and they were floating on a silver cloud.

The difficult HIV discussion and test in the early days of their relationship was long forgotten, and Jay even took it upon himself to help Joyce remember to keep to her clinic appointments and blood tests every six months, reminding her to get her ARV refills on time and take her pills exactly at the right times. He was taking a lot of interest in her CD4 counts too, as well as being sensitive to her sad days - usually on the days when her blood was taken for testing - trying his best to be as supportive and loving as possible.

But, despite all the good things happening in her life, Joyce’s cancer diagnosis was hanging over her like a dark cloud. Her employer, Yvette,

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immediately noticed that something was wrong when Joyce came in for work the week after she was told the ‘bad’ news. ‘What’s wrong?’ she asks, as Joyce is taking her new ARV tablets out of her handbag. After living with HIV for more than ten years, Joyce has no problem being open and upfront about anything in her life to Yvette, telling her right away what the doctor had told her the previous week.

‘At the clinic, they told me I have cancer now… and they put me on new ARV pills.’ ‘What! Cancer? Are you sure? What type of cancer? And how can they just change your ARV regimen like that?’ exclaims Yvette in shock. ‘I don’t know … my CD4 count is good and my viral load is undetectable, and I have not had any bad side-effects from the other ARVs. They also gave me a new tablet for depression and the painful pins and needles in my hands and feet … that I have to take in the evening before I go to bed.’

‘Then you must get a second opinion Joyce. Have you been to see another doctor? Cancer is a serious diagnosis and you need to see a cancer specialist and get the right treatment as soon as possible. What is the name of the new doctor at your clinic?’ asks Yvette. ‘I don’t remember. It was so busy there with all the patients … and I never saw him before … and I got so scared … I forgot most of what he told me’ whispers Joyce, on the brink of tears. ‘Come here, give me a hug.’ Yvette embraces Joyce, and then calmly explains that they will get in the car right away and go to the clinic and sort this all out.

Arriving at the clinic, Yvette can’t believe how many people are standing around in the hallways waiting to be seen by the doctors. There seems to be general chaos, but Joyce explains that each patient gets a number as they come in, and then waits their turn to have their ‘vitals’ taken by a nurse who writes down their weight and blood pressure in their patient file. Sometimes people wait all day before they can see a doctor. After what seemed like hours, Joyce’s patient file was pulled and they managed to see one of the nurses on duty who knew Joyce well. Opening the file and paging through it for a few minutes, the nurse explains that according to her last blood tests, Joyce is doing very well and that there is no need to see a doctor today. Or change her ARV regimen for that matter. Angrily Yvette explains to the nurse that Joyce was told the previous week that she has cancer and demanded to know why her ARV regimen was also changed for no reason.

‘There must have been a mistake … or some kind of mixup’ the nurse answers. ‘Joyce are you sure you were given your file last week when you saw the new Doctor?’ ‘I … I don’t remember … I was not feeling well that day … there was a lot going on’ she answers, feeling a bit stupid and thinking of Jay, wishing that he was here with her now.

Evidently the new doctor, who did not know Joyce, had mistakenly read results from another file for another patient and given her the wrong information. Joyce, who was always so careful and never missed an appointment, never even skipped a dose of pills, and always wrote her CD4 count down on a card in her purse, was shocked all over again. In a hurry to see a doctor quickly - so that she could go and meet Jay - she did not notice, somehow, that she was given the wrong patient file!

Taking her by the hand, Yvette says calmly: ‘Take the rest of the day off Joyce.’

Visibly shaken, but very much relieved, Joyce waits at the side of the road for the next taxi to take her home. She thinks of Jays’ kind eyes and sweet smile, hardly noticing the noise of the rush-hour traffic, or the warm orange glow of the setting sun. She pulls her cell phone from her handbag and then punches in a text message: ‘Hi my love.

Would U like to come over for dinner tonight, around 7:30 … and stay the night? I have a bottle of cold wine ; )’ Joyce finds Jays’ number and presses ‘SEND’.

We asked some CD4 readers why it is so important to ‘work together with your doctor or health care providers’, and to take charge of maintaining your own health and informing yourself as much as possible about treatment options available today:

BE IN CHARGE OF YOUR OWN HEALTH AND WORK TOGETHER WITH YOUR DOCTOR! THABO NHLAPO

Working together with your doctor, nurse, social worker, etc. creates a good relationship between you and them. It helps build an environment of trust where there is freedom of talking to your health care provider about anything that concerns your health.

Taking charge of your health means that you alone are responsible for your own well-being and that you value your own health very much.

This will enable you to know more about treatment options that are available to you. It will also help you and your health care providers to know which treatment you should access, along with its possible side-effects and the foods that you need to avoid or reduce in your diet, and also things – like smoking and drinking – that you need to cut back on or stop completely. When you have open communication and an honest relationship about what is happening with your health with your health care providers, it will make things easier for you and your doctor!

If you are seeing a counsellor, you must work together, as it will also help you to deal with situations you might be facing in your life. They will guide you onto the right path by offering you suggestions as to how to go about dealing with whatever concerns you may have that are troubling you.

It is of vital importance that you work together with your doctors, nurses, counsellors, social workers, etc. in order to have a better understanding about what is going on with your health. It will also mean that you are working towards achieving the most important goal: taking “charge of your own health and well-being” and empowering you – as a patient – and to get the correct treatment.

Joyce failed to get any clarification – or a second opinion - on what she was told by the new doctor at the clinic. She could have taken the new ARVs she was given and that could have put her health in danger; fortunately she got help and found out that she was misdiagnosed. So having a fabulous, open and honest relationship your social worker or doctor means you are contributing to having a healthy life!

Southern African Sexual Health Association www.sexualhealth.co.za

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LEIGH MAFTIPA We all know that a person’s health and wellbeing include physical, emotional and spiritual factors. Maintaining your health isn’t about eating healthy food only, it also has to do with exercising, going to church and prayer - as well as protecting ourselves from HIV and STIs when we are going to engage in sexual intercourse. These days there are many opportunistic infections - like TB, Malaria and Cancer etc. – and not only do they infect people living with HIV, but also people who are HIV negative. If you are living with HIV you need to minimise the chances of contracting any of these opportunistic infections.

In most cases people don’t want to consult their doctors or nurses when they feel that something is wrong with their health or body.

Some people prefer a traditional doctor. However, traditional doctors can cure some diseases but a medical specialist is your best choice for treating HIV, as these experts are professionally trained to deal with issues around HIV. It is vitally important that we work together with our doctors and nurses – rather than with our traditional healers. A person living with HIV needs to know what their CD4 count and Viral Load is. A traditional healer can’t provide that kind of information, and medical doctors and nurses are the only ones who are trained about the treatment of HIV and many other related health concerns. They are best able to advise one on how to maintain our own health for us to always stay healthy.

We all know that HIV/AIDS is affecting our nation and one of the most difficult things a person has to face - when diagnosed HIV-positive - is the hard reality for us to accept our HIV status. It is good to know that we have counsellors to help us – these are people who are trained and can help us to deal with this news. It is normal to be scared, however, people should try to communicate with counsellors so that they are well informed about all the implications of this disease. ‘HIV’ has never killed anyone – but opportunistic infections do, when your immune system no longer keeps you healthy. Depression and stress can be managed by talking to your counsellor – they are there for you to talk to about all aspects of your life!

Depression and stress are not caused directly by our ‘health status’, but rather by pressures and stigma from society. Stress and depression are two things we don’t need - especially when we are living with HIV. Family problems and issues at home are not always easy to overcome, but we have the right people available at our clinics and hospitals (like social workers) who can help to minimise our worries They might not help with all problems but they can do their best in minimising them, as they are trained as experts in dealing with emotional issues. As human beings we need to talk about our problems! If we don’t - and we keep them to ourselves - they might destroy us. People must start realising that we cannot solve problems all on our own. We need to share them with someone. Social workers and VCT counselors are there for us to talk to. Our family and friends are not always a good source of information so we need people who are well informed on how to deal with HIV issues.

Today we have different treatments for different types of diseases and it is important that we know the relevant treatment options for a specific infection we have e.g. we have different types of ARV drugs and they are given to different people because people don’t have the same strain of HIV in their bodies. It is very important that we get educated about all our medications and lifestyle choices. It is most important that we see our doctors and nurses regularly for check-ups and follow-ups. They are the ones who can best inform us about all the types of treatments that can be most affective to our specific situation - especially when we are living with HIV. BOITUMELO SEKHU Working together with our doctors, nurses, social workers, counsellors and health care providers is important as they are trained professionals and they also know what is best for their patients. If they tell you – for example – what you should do for your health and well-being … like what medications to take, what time, etc.

- it is your responsibility to do exactly that and follow their instructions to the letter.

You must also try to understand why and how ARV treatments are prescribed the way they are. Ask questions and learn as much as you can! Doctors and health care providers are there to help and guide you, but ultimately it is up to you to take charge of adhering to your prescribed regimen and making sure that you have optimum health and well-ness.

Our health is very important, and we should take care of it best we can. Inform yourself and find out as much as you can – and if you feel that you need a second opinion, make sure you get it from a reliable source.

Counsellors and social workers are also there for us when we need to talk to someone and get things off our chest, especially when we don’t have anyone whom we can trust to talk to about the difficult issues around living with HIV, our happiness and well-being.

It is very important that we inform ourselves about all possible treatment options available to us. It is our right as human beings to be healthy and access appropriate health care – and nowadays it is relatively easy to access HIV care and treatment at Government ARV hospitals and clinics.

PRUDENCE MHAULA “It’s my life; and my doctor is also my ‘helper’ in living a good and healthy life-style!”

As human beings we do need each other in life – and this basic need also applies to my relationship with my doctor. Having a close - but professional - relationship with my doctor helps me to know more about my general health – and specifically illnesses that may affect my state of well-being and quality of life in the present and in the near future.

One of the most important things I have to think about is the way I choose to live my life - and especially taking charge of my own health.

Whose life is it? Mine. Who should be responsible for it? Me! A doctor specializing in HIV is your best friend and is there to assist you in all medical matters, and also to guide you in taking your ARV medications and making sure that you’re getting the treatment that you should be getting - like if you have to change the ARV regimen that you’re taking when it is not working for you, or if you are experiencing adverse side-effects.

Talking honestly to your doctor about the changes you feel in your body and telling him - or her - what your needs are is very important. Always ask to take a look at your medical file with your treatment history to see how you are doing – especially making a note of your Viral Load and CD4 count.

Inform yourself all the time about HIV and ask questions about the things you don’t understand. This may help you to know the latest information about your own health – and in the event that your file gets lost – as in this case with Joyce - you will be able to update your doctor or care-giver about what is going on with your physical condition. Make a note of all your latest CD4 count and Viral Load test results – and write them down in a safe place in case you need them. Also try to remember the names and dosages of all the medicines you are taking – in case you need a refill in an emergency or when you are traveling!

Confide in your doctor, and develop a good relationship with all your care-givers – nurses, pharmacist, etc. and familiarize yourself with the names of your medications!

UP

KEEPING YOUR WEIGHT In the early days of the HIV epidemic, one of the biggest problems people faced was AIDS-related wasting. ‘Wasting’ commonly involves involuntary loss of weight or lean body mass. The strict definition adopted by the Centers for Disease Control and Prevention (CDC) involves a loss of more than 10% of body weight.

Today, fortunately, effective treatments for HIV have made wasting, along with AIDS-related dementia, Kaposi’s Sarcoma (KS) and other AIDS-defining conditions much less common. But maintaining body weight is still sometimes a problem for people with HIV. HOW MUCH OF A PROBLEM? The truth is, we don’t know to what extent involuntary weight loss and wasting occurs among HIV patients today.

Certainly with the availability of Highly-Active Anti-Retroviral Therapy (HAART), opportunistic infections and wasting have declined. We’re not seeing the number of cases that resemble ‘skeletons’ like we saw before 1995 and today wasting, although still present, can be a lot more subtle in the way it presents itself.

THERE ARE TWO GROUPS OF PEOPLE WHO STILL SOMETIMES HAVE PROBLEMS WITH INVOLUNTARY WEIGHT-LOSS: 1. Some involuntary weight-loss that results in wasting may occur among HIV patients on HAART where the virus is well-controlled. This sudden loss of weight can also take place due to relatively mild challenges such as a bout of stomach flu or diarrhoea and it’s sometimes very hard to regain the lost weight.

2. Another example also occurs in patients on HAART who are doing fairly well with viral loads that have dropped significantly. Often their physicians or friends notice that they have become thinner and although the change can be very gradual it sometimes seems to be more sudden.

It is in these instances where resistance to medication may play a role.

IF YOU WEIGH LESS THAN YOU WOULD LIKE, WHAT ARE YOUR OPTIONS? The first step is to look for an underlying reason. Less-thanideal control of your viral load or developing resistance to medications may make you more susceptible to wasting. In earlier years, wasting was one of the first signs that HIV was turning into AIDS. Have your doctor check your viral load and your CD4 cell count, and review your therapy. Another strategy is to re-consider your diet and exercise program.

Of course, you want to make sure your nutrition and exercise program is optimal. You don’t want to exercise so much that you’re burning lots and lots of calories, but the addition of resistance exercise (weight training) can help people build lean muscle mass. Again, consult with your physician and a dietitian or nutritionist for advice.

If those steps don’t work, you might consider an appetite stimulant like megestrol acetate (generic name) or an

anabolic steroid like oxandrolone (generic name) that is approved for the treatment of wasting by the U.S. Food and Drug Administration. Somatropin (generic name), a recombinant Human Growth Hormone (r-hGH) is the only therapy for HIV-wasting FDA-approved to increase weight and lean body mass, and improve physical endurance.

Human Growth Hormone works in different ways. It has an anti-catabolic* effect: it reduces the breakdown of muscle tissue. At the same time, it builds up the amino acids and proteins in muscle, which is an important part of your lean body mass.

So it both protects the muscle from breakdown and at the same time promotes its growth.

Another product you might consider to help build lean body mass is a medical nutritional product that contains a patented blend of arginine, glutamine and β-hydroxyβ-methylbutyrate (HMB) that helps build lean body mass, which has long been popular in the HIV community.

• HMB helps increase lean body mass, reduce body fat and increase total strength.

• Arginine helps enhance the immune response and wound healing.

• Glutamine helps support the immune system and protein synthesis.

These kinds of nutritional products have been on the market since 1994,” says Tracy R. Smith, PhD, RD, LD, a research scientist with Abbott Nutrition. This kind of product got its start in the HIV community, and already had quite a following at that time.”

“Nutritional products that contain a patented blend of arginine, glutamine and HMB were tested among sedentary HIV patients who had lost 5% of their body weight” Dr. Smith says. “In an eight-week test, those taking this nutritional product gained an average of 2.5 kilograms of lean body mass, while the control group lost 0.7 kilograms of lean body mass. It’s a great-tasting, simple-to-take solution for people who are losing lean body mass due to HIV or cancer. Lean body mass is functional tissue-organs, muscle, and skin-that is vital to life. It is critical for HIV patients to maintain their lean tissue in order to feel well, fight infection and remain independent.

There are several products on the South African market that are either pure growth hormone products or combinations.

Furthermore there are products that contain arginine and glutamine available in South Africa and that are locally produced and could possibly be cheaper. *Anti-catabolic: Reacting against catabolism. Preventing breakdown of the body or its parts.

Adapted by kind permission from HIV Positive! Magazine, article courtesy of Doctor Eric S. Freedland, MD, Director of Medical Affairs for Serostim at EMD Serono, Inc. Copyright 2008, Positive Health Publications, Inc.

Southern African Sexual Health Association www.sexualhealth.co.za

issue 04 CD4

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discordant* couples

GAY

I

n this issue we focus on positive living for gay men, recent findings on new HIV infections and touch on certain aspects of living with HIV. HIV can make you more vulnerable and it is greatly stigmatised but it can also be a growth experience.

There are many questions. What about relationships, how do I establish a loving and fulfilling relationship when I (or my partner) is HIV positive? Do opposites attract? Can I have a relationship with a partner with a different HIV status? These questions seem daunting and can make you feel that a HIV+ diagnosis is too difficult to handle and that it is easier to deny realities. But, take a small step, get information and start loving your body and mind.

MORE INSIGHT INTO RECENT HIV INFECTIONS In general, gay men are well informed about the risks with unprotected anal sex but there are diverse psycho-social reasons why they do not always practise safer sex. From an INSIGHT study which was presented at the recent British HIV Association 12th Year Congress, some new insights came to the fore. The study investigated risk factors with homosexual and bisexual men in HIV sero-conversion.

A first finding was that condoms stand in the way of intimacy, trust and spontaneity. This is true in a committed relationship as well as with casual partners.

A second interesting finding was that respondents who seroconverted had a form of anal sex which were viewed as less risky. As an example, the anal sex was insertive rather than receptive, gentle rather than intensive and wild, lots of lube rather than nothing or little, or the sex was short. The men also felt that they were not the type that will get the virus.

They are not promiscuous, do not do drugs and are not part of the gay subculture. A lot of respondents previously tested negative and viewed this as indicating resistance to getting infected or as proof that risk reduction behaviours (such as insertive rather than receptive anal sex) work.

and living with HIV

who wanted to practise safer sex but did not do it, had loss of control because of low self esteem and depression.

It often results in drug and alcohol use with detrimental consequences to choose safer sex. As one respondent said depression has a big influence on my sexual behaviour. It is almost if I want to be used…..you have the feeling that it does not matter if others do with you what they want.

RESILLIENCE HIV can have a big impact on your life. Over and above physical complaints, you can be confronted with mental health issues. You can feel inferior, vulnerable and maybe less attractive.

HIV is often called the second ‘coming out’. A lot of HIV+ people feel that they can’t tell friends and family because they fear rejection and losing contact. There is still a lot of stigma around HIV. HIV related stigma is rooted in the seriousness of the disease and that it evokes anxiety. Stigma can have serious consequences for people with HIV. On a social level it can result in breaking of ties with family, friends and colleagues. It can also be difficult to enter into new relationships, with friends or lovers.

Stigma can lead to anxiety and depression. You can develop lower self esteem through internalising someone else’s prejudice and this has effects on your health. Anxiety and prejudice against HIV (also in yourself) is deep seated.

One way to address this is to start changing stereotypes of people who are HIV+. They can be young, beautiful, intelligent and full of life. Get to know people who are HIV positive, they are real people living real lives.

HIV can give you a new perspective on life. You can decide to live more in the now. Maybe before HIV, you could find excuses to make the now less important. Living with a chronic illness can make you live for that what is really important.

A third finding was respondents’ optimism around ARV combination therapy. It is commonly believed that younger people share more of this optimism. The study found that it is more common for older gay men to see HIV as less of a threat because of the availability of combination therapy.

Older men felt that getting sick is part of aging.

People in your environment can react differently to what you expected. Maybe you expect negative reactions, but a supportive reaction is very possible! Good reactions can make you more resilient. Make yourself strong against negative feelings and negative reactions from others. You have HIV and you would need to find a way to live with that.

Why not try and make the best of it?

Lastly, it was found that depression, low self esteem and a lack of control result in unplanned, unprotected anal sex.

It was found that respondents who recently sero-converted,

You are not worth any less because you have HIV. To make yourself stronger is a process, and some people take longer than others to do so. It is necessary to look inside. How do

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Southern African Sexual Health Association Helpline +27 086 100 262

you feel about HIV? How you deal with HIV is important in how others will deal with it. Comments that enforce stigma will affect you less when you are well informed and feel strong.

You can work on your own to make yourself stronger. Some people need some assistance. You can go on courses, join a support group or speak to a therapist.

Or you can contact community groups such as OUT on 012. 344 - 6500 Triangle Project on 021. 448 - 3812, Durban Gay and Lesbian Centre on 031. 301 - 2145.

RELATIONSHIPS AND INTIMACY With HIV, life can seem different. The start and continuation of relationships will also be different.

Starting new relationships are different to when you did not have HIV. You meet someone hot and you ask yourself the question: do I tell him that I have HIV or do I wait? Maybe you are afraid that he will walk away. You start thinking that it will be better to wait till the contact is more intense and when you know he will not walk away when you tell him. It is difficult to say if there is a best way and time to tell. If he reacts negatively, try that it does not affect you too much. It is easier when he is also HIV+. If you wait for too long, it does affect intimacy. To be open is a way to be coresponsible for keeping the sex safe.

a HIV test. It is not romantic especially at the start when you both live on a silver cloud. But it is a fact that most new HIV infections occur within relationships. That is not romantic.

What if one of the partners tests positive for HIV? Some HIV discordant couples (technical term for when one partner has HIV and the other not) have no problem with the virus.

Their biggest issue could be who does the dishes. But with some the difference in HIV status results in tension, questions and unclarities. A vital part of any support that should be offered to people in sero-discordant relationships is the understanding that HIV can affect both people equally.

Many mixed status couples have major problems dealing with mental health problems. It is also too common for the negative partner to be almost forgotten when the positive partner seeks support and advice. The negative partner’s health needs to be protected and the positive partner needs the support of the person closest to them to come to terms with their diagnosis.

One question, when your partner has HIV, is how long he will still live. One can not answer this question. Your partner could have HIV for some time without any serious complaints. It is very likely that your partner reacts well to ARV combination therapy that fights the HIV in his body.

But combination therapy has only been on the market since 1996 and it is difficult to say what their long term effects are. It is important not to panic with every cold and flu.

People with HIV also get a normal cold, and it is not the start of the end.

Your loving partner can support you and deepen the relationship. He could also not support you. Keep in mind that he can have his own anxiety around issues of HIV. Most men in committed relationships are open about HIV and that keeps the relationship honest and healthy. It is important to keep communication channels open. Say what you think and feel and ask your partner to do the same. When you two find it difficult to do this, get assistance from a third party. It can be a good friend, support group, helpline or a therapist.

One question, when your partner does not have HIV and you do, is how you can protect him against HIV. Using a condom when you have anal sex is the best protection against HIV. However, it is not that simple. Even if you use condoms, you can still have anxiety that you can infect your partner. These feelings can cause less enjoyment of sex. Be aware of these anxieties and be open to each other. Talk about your boundaries and find out about your partner’s boundaries. Try to not allow that HIV dictate your relationship too much.

With gay men (with or without HIV) sexual contacts are an important way to establish friendships. If the sex falls away, for whatever reason, they would need to find new ways to make friends. If you are afraid that you will be lonely, you could explore other forms of social contact and intimacy.

There are lots of possibilities. You can start a film, theatre or meal club with people you know. You can also join a gay sport club; sport is anyhow good for your body and mind.

Your attractiveness for other men does not only depend on your muscles and six pack. It is also about your energy. If you are comfortable with yourself, it will show and other people will be attracted to this. With HIV you may feel more insecure than before. Are you still attractive? Are you still good enough? It is important to regain your self confidence.

It is easier for others to like people who like themselves. Of course this is easier said than done. You can always knock at the door of professionals to help you do this.

When the condom breaks, you can consider taking PEP (Post Exposure Prophylaxis). PEP is the medication that in most cases prevents becoming infected with HIV. You need to start taking it within 72 hours after exposure. It is a HIV cocktail that you would need to take for a month.

OPPOSITES ATTRACT There are all sorts of questions when you have a new lover.

Are we going to stay together? When do we tell our friends and family? Another question in a lot of gay relationships is whether one or both partners have HIV. With the start of a new relationship, it is important that both partners go for

*Discordant couple: A pair of long-term sexual partners in which one has a sexually transmitted infection and the other does not, such as when one partner tests HIV+ and the other HIV-.

This article was written by staff at OUT:

Lesbian/Gay/Bisexual/Transgender (LGBT) Well-being.

It is based on information from the Schorer Foundation (the Netherlands) and the Schorer website: www.homohivplus.nl.

A useful site on sero discordant relationships is www.positive-negative.org.

Southern African Sexual Health Association www.sexualhealth.co.za

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Positive Sexuality

UNDERSTANDING ‘diversity and gender’

BY ERIC M. RICHARDSON AND MARGARET ROPER

“Mainstream HIV/aids campaigns ignore the LGBT community. Lesbian, gay, bisexual and transgendered communities require HIV-prevention education that is LGBT-sensitive and gender-sensitive. HIV/aids education programmes offered to LGBT people can, and indeed should, engage with gender inequalities”.

In South Africa, organisations involved in HIV/aids education and support should not neglect the unique needs of lesbian, gay, bisexual, or transgendered (LGBT) people - or people involved in same-sex relationships. When working with LGBT communities, HIV/aids education, support programmes and care providers should engage with sexuality, gender norms and inequalities which inhibit certain people from being able to say no to unsafe sex.

Research suggests that for many Africans, homosexual behaviours have nothing to do with a person’s identity.

Instead, many Africans believe that ‘gay’, ‘lesbian’, and ‘bisexual’, are Western ideas … unsuited to African sexualities and experiences. There are however many men involved in same-sex experiences or relationships – or “men having sex with men” (MSM) - that do not see themselves as being ‘gay’ or ‘bisexual’. Similarly, there are “women having sex with women” (WSW) who do not see themselves as being ‘lesbian’.

Strategies aimed at reducing HIV/aids infections are not likely to have an impact on these people, unless they recognise that ‘MSMs’ and ‘WSWs’ do not see themselves as being the same as gays, lesbians or bisexuals.

Homosexuality remains stigmatised, and people involved in same-sex behaviours or relationships may not wish to discuss their high-risk sexual behaviours with doctors or health care workers for fear of discrimination or being labelled “inappropriately”. Male youth and men who fear being labelled as ‘gay’ may engage in heterosexual sexual behaviour so as to prove that they are “normal”, thus exposing themselves, and all partners, to increased risk of infection. As “boys” and “men” they may also refuse to get advice on how to avoid HIV infection. Some MSMs marry because of social pressure.

Since the focus of most HIV/aids prevention and awareness campaigns in South Africa have addressed the heterosexual transmission of the virus, men who have sex with men lack page 28

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sexual health information to enable safer sex practices and behaviour.

A final group of people are transgender people. Although the term “transgender” is used to refer to anyone whose self-identification ‘breaks the rules’ of recognized ‘male/ female’ gender categories, a transgender person can be lesbian, gay, bisexual, or heterosexual. Not much is known about the transgender community and more South African research is needed in this area.

Many transgender people are involved in unprotected sex, sex work, and substance abuse (sharing of needles), thus making them increasingly vulnerable to HIV infections.

Mainstream safer sex campaigns do not consider the needs of South Africans who believe that their gender identities do not correspond with their biological bodies and the medical sector also find providing health services to the transgender community difficult, and they are not necessarily equipped to engage with the range of sexual identities beyond ‘lesbian’ and ‘gay’. Although doctors have indicated that they treat all clients equally, a transgendered patient comes with additional experiences and differing HIV/aids and sexual health needs.

LGBT GENDER ROLES AND RELATIONSHIPS There is a tremendous amount of pressure on LGBT people to imitate ‘normal’ heterosexual relationships. Some youth do conform because they need to feel that they are accepted.

For example, a young gay man may take on an effeminate role because his boyfriend wants to be the “masculine” one, and a large percentage of these men tend to be victimised, oppressed, and more effeminate. Many individuals lack to the power and coping skills to negotiate or conduct safe sexual practices and are therefore vulnerable, and more at risk, of infection (from STIs and HIV) and victimisation. As a result they have tended to take on the more ‘feminine role’, role-modelling heterosexual relationships. These ‘normal’

Southern African Sexual Health Association Helpline +27 086 100 262

Positive Sexuality relationships, in which one person plays a ‘masculine’ role and the other a ‘feminine’ role, might not promote equality, dignity, or freedom.

In some gay couples, for example, one of the men may be more “masculine” while the other is more “feminine”. These gender characteristics then impact on their roles within the relationship, with the “masculine” man being the one who penetrates during sexual intercourse - and may also restrict the practice of safe sex. He may be more controlling and promiscuous. Like many women in heterosexual relationships, the other man may accept the partner’s dominance and control, and may struggle to insist that his partner practice safe sex.

In gay relationships of inequality, threats of violence or abandonment may result in one of the partners being coerced into receiving unprotected anal sex. Unprotected anal intercourse, regardless of the partner’s gender identity, poses an especially high risk of HIV infection for the receptive partner, because the lining of the rectum is thin and can easily tear. An infection in the rectum may also go unnoticed, increasing the risk of STIs. In lesbian relationships, one of the partners may also experience violence at the hands of her lover.

STRATEGIES TO REDUCE LGBT RISK AND VULNERABILITY Given the nature of their sexual relationships, LGBT people are more vulnerable to, and at a greater risk of, HIV and AIDS. Anal sex, for example, is a high-risk activity for HIV infection as the rectum is tender and tears easily. This can occur during penetration; condoms produced for the mass market can break during anal penetration, resulting in increased risk for contracting STIs and HIV. Men can be infected from the transfer of semen or pre-ejaculation seminal fluid during oral sex or from using unclean or shared sex toys; and vaginal fluids can be shared resulting in HIV transmission between women.

LGBT people must be enabled to raise concerns and issues, and openly express biological, physiological, and social aspects of their sexual relationships, in the hope that they will learn how to negotiate behaviour between partners.

Organisations involved in HIV health work must consider the feelings, relationship behaviour, roles, social norms, and the use of condoms of LGBT people - and also consider the following recommendations: 1)

Consider the distinction between ‘feminine’ and ‘masculine’ in gay and lesbian identities, and how they relate to the spread of HIV and AIDS. These differences in gender and sexual identities do affect how individuals view themselves, take on roles and responsibilities in relationships, access health services, and respond to core messages of sexual health, positive living and self-identity.

2)

Recognise that same-sex violence is a reality, and that interventions may need to enable one of the partners to negotiate safer sex.

3)

Challenge gender norms and roles and encourage people to examine and question ideas about “masculinity”, “femininity”, and the roles of men, women, boys and girls; and enable people to recognise alternative versions of masculinity and femininity.

4)

Develop programmes which promote more genderequality between sexual partners.

5)

Acknowledge the reality of young people’s sexual experiences. HIV/aids education aimed at the LGBT community should include an emphasis on and engage them in discussions on their life experiences, sexual experiences and sexual identity. Similarly, mainstream HIV/aids education targeting youth should incorporate LGBT issues to increase acceptance and enable new understandings of gender norms and sexual behaviours.

“Gender-equal” practices will not only reduce risky sexual behaviours, but also help to reduce gender-based domestic and homophobic violence found in some same-sex relationships.

HIV PREVENTION AND AWARENESS CAMPAIGNS Mainstream HIV/Aids campaigns tend to ignore the LGBT community. These safer sex campaigns are aimed at “feminine women and masculine boys” engaged in heterosexual relationships. Because of this heterosexism, LGBT youth do not identify with the imagery, culture or behaviours being advocated. Clearly, if we are trying to use these campaigns to reduce the spread of HIV/Aids this is a problem.

Reaching LGBT people requires a LGBT-sensitive approach.

LGBT people, who receive HIV education and information appropriate to their life-styles, tend to have fewer sexual partners, less frequent substance abuse before sex, and less risky sex. HIV/aids programmes offered to LGBT people must also engage with gender inequalities and requires an engagement with the realities of their lives and the ‘gender’ relations that constrain their safe sex practices.

To reduce the risk and vulnerability of the LGBT community, HIV/aids organisations must develop life-skills and healthy sexual relationships based on sound information and access to condoms, femidoms and denti-derms – including the prevention, detection and treatment of STIs, and the prevention, treatment and care of HIV and AIDS. We must endeavour to influence behaviour through providing sound information, facilitate safer sex, and openly discuss appropriate and desirable sexual relations. Key to this is the empowerment and self-esteem of individuals so that they can have positive relationships and sexual health.

The Joint Oxfam HIV/AIDS Program funded the study for the paper on which this article is based.

Ask the Doctor

HIV and Nutrition

By Dr Anton Janse van Rensburg

Nutrition in HIV/AIDS has received media coverage for some time now and I’m quite sure it has left many people with more questions than answers and more confusion than clarity!

In this article I would like to address common questions that are asked with regards to HIV/AIDS and nutrition.

1) DOES NUTRITION PLAY A ROLE IF I HAVE HIV? The greatest reason for immunosuppression in the world is malnutrition. Combine this with active HIV infection and you have a bad scenario as HIV can cause bad absorption of nutrients as well. It is thus crucial that people living with HIV/AIDS (PLWHA) look after their intestinal tracts and take the right nutrients.

2) WHAT SHOULD I EAT? Here is a list of immune-strengthening things you can do: • Consume 6 - 8 glasses of clean water every day.

• Try to eat six smaller meals a day instead of 2 -3 large meals. Note: people who eat large meals have suppressed immunity!

• At least two of the six small meals you have every day should consist entirely of fruit and vegetables. A good parameter is to eat five portions of vegetables and five portions of fruit EVERY day. It is highly advisable to work towards a diet that is 75% raw fruit, vegetables, nuts and seeds, and 25% cooked food.

• Try not to have animal products every day. Have animal products three times a week, preferably free range chicken and beef; fish can be fresh or tinned. Use plant proteins on the other days of the week (e.g. beans, pulses, Soya).

• Try to use organic animal and plant produce if possible.

These are products that are made without the use of dangerous pesticides, preservatives, hormones etc.

• Start a cooked meal with a salad. The salad contains enzymes which assist the digestion process.

• Healthy fats are very important. Have foods on a daily basis that contain healthy fats like avocado, raw nuts and seeds, raw corn on the cob, and fish. Healthy cooking oils are olive oil and palm fruit oil. Eat your olive oil raw to get the full benefit.

• Snack on raw vegetables and dried fruit instead of sweets and refined snacks.

3) WHICH FOODS SHOULD I AVOID? There are some foods that can really make life hard for your body’s defences. Avoid the following list of foods and you will definitely be better off: No damaged fat!

This is very important, even for people who do not suffer from HIV. Damaged fats are formed when weak oils like sunflower, Soya and canola are heated to cook food.

Because these oils are not strong enough to handle the heating process dangerous chemicals are formed that suppress the immune system. Damaged fats are also found in potato chips, most refined foods, french fries (chips), vetkoek, koeksisters, most snack biscuits, some breads, soups and sauces in packets. Another form of damaged fat is hydrogenated oil and this occurs in many refined and processed foods. Learn to read product labels to avoid these toxic oils. My advice is that you try to avoid cooking in page 30

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oil altogether. Learn to cook food in water and steam your vegetables.

AVOID preservatives, colorants, and chemicals These are found in crisps, most salted snack biscuits, some breads, soups and sauces in packets, sweets, cold drinks and most refined, processed foods. A basic rule is that food needs to go bad in a few days and not last for months on the shelf. Otherwise it probably contains some weird chemicals that you would rather avoid but even then you should just read the label.

AVOID too much salt Studies have shown that due to the fact that salt occurs in so many processed foods the average person gets way too much salt and this causes conditions like hypertension later in life.

AVOID sugar and any other refined carbohydrates Sugar is an immune suppressant and should definitely be avoided! Apart from avoiding sweets and soft drinks, you should also avoid refined-sugar foods - also called high GI (Glycemic Index) foods - like white bread, pizza, pasta and refined white maize meal.

Alcohol Alcohol is an immune suppressant. You’ll be better off avoiding it all together.

Caffeine Caffeine destroys certain micronutrients in the body and can cause an individual to be more anxious, which is not good for the immune system.

4) CAN I TAKE ANY SUPPLEMENTS? Although I really advocate the use of nutritional supplements in PLWHA, I also advise caution. Due to some herbal supplements possibly interfering with anti-retroviral therapy (ART) I would suggest that you visit a doctor who knows nutritional supplements to help you in this regard.

A safe place to start?

The reality is that many people do not have the finances to afford a variety of expensive supplements and are thus left with the cheapest multi-nutrient preparations available.

This does not seem to be a problem in the light of research that was done in Bangkok and Tanzania that determined that even a ‘cheap’ multivitamin can decrease mortality and improve quality of life in PLWHA to some degree. So, even if you can only afford a cheap multivitamin, it’s still a good idea to use it. Some of the more affordable multinutrients in South Africa do contain the recommended daily allowance for vitamins and minerals for an adult. Make sure you read the label before buying it.

Extra vitamins and nutritional supplements can enhance your health but should not replace a healthy diet. It’s always important to remember that healthy and nutritous food that you eat is the most important when it comes to health and vitality!

Read more about HIV and nutrition on my website at www.thesourcesa.co.za

Southern African Sexual Health Association Helpline +27 086 100 262

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CITY OF JOHANNESBURG & WEST RAND CONTACT NUMBER PRIMARY HEALTH CARE

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HOME BASED CARE

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BABIES / CHILDREN

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HOSPICES

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CITY OF TSWHANE & METSWEDING

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HOME BASED CARE

Atlegang Community Organization Boikanyo Home Based Care Hlolanang Home Based Care Kholofelong Led Organisation Nani Home Based Care Sizanani Home Based Care Tateni Home Based Care Services

072 045 7793 013 975 7000 012 373 0828 012 998 1822 012 800 2818 072 590 1595 013 932 6600 012 805 6877

BABIES / CHILDREN

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HOSPICES

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BABIES / CHILDREN

CONTACT NUMBER PRIMARY HEALTH CARE

Adelaide Tambo Clinic Atteridgeville Clinic Boikutsong Clinic Danville Clinic Dr FF Ribeiro Clinic Folang Clinic Gazankulu Clinic Hammanskraal Primary Health Care

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Break-Through Centre Chubby Chums Villa Lisa Support Group

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HOSPICES

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