IMPORTANT NOTES NORMAL LABORATORY VALUES TERMINOLOGY IMPORTANT NOTES: Each commercial laboratory has its own set of “normal” values, called “Normal Range” or “Reference Range” on your lab report. These values depend on the equipment or method used. Compare your results to the range shown on your lab report. Results that are “out of range” may not represent a problem. Your test results can be affected by several factors, including your age or gender, if you are pregnant, the time of day when the sample was taken, active infectons, stage of HIV disease, and food (some test samples need to be taken after you have fasted – not eaten anything – for several hours). Where normal values for men and women are different, they are indicated as W for women and M for men. Discuss “out of range” results with your health care provider. The table below compares the units used in the United States with the "Système International d’Unités (SI units), a metric system used in many parts of the world. The last column, "To Convert US to SI Units," is the factor to multiply US lab values to convert them to SI units. To convert SI units to US units, divide the SI value by the conversion factor. See page 2 for a terminology list. NORMAL LABORATORY VALUES Laboratory Test Normal Range in US Units Normal Range in SI Units To Convert US to SI Units ALT (Alanine aminotransferase) W 7-30 units/liter M 10-55 units/liter W 0.12-0.50 µkat/liter M 0.17-0.92 µkat/liter x 0.01667 Albumin 3.1 – 4.3 g/dl 31 – 43 g/liter x 10 Alkaline Phosphatase W 30-100 units/liter M 45-115 units/liter W 0.5-1.67 µkat/liter W 0.75-1.92 µkat/liter x 0.01667 Amylase (serum) 53-123 units/liter 0.88-2.05 nkat/liter x 0.01667 AST (Aspartate aminotransferase) W 9-25 units/liter M 10-40 units/liter W 0.15-0.42 µkat/liter M 0.17-0.67 µkat/liter x 0.01667 Basophils 0-3% of lymphocytes 0.0-0.3 fraction of white blood cells x 0.01 Bilirubin – Direct 0.0-0.4 mg/dl 0-7 µmol/liter x 17.1 Bilirubin – Total 0.0-1.0 mg/dl 0-17 µmol/liter x 17.1 Blood pressure Normal: 120/70 to 120/80 millimeters of mercury (mmHg). The top number is systolic pressure, when the heart is pumping. Bottom number is diastolic pressure then the heart is at rest. Blood pressure can be too low (hypotension) or too high (hypertension). No conversion C peptide 0.5-2.0 ng/ml 0.17-0.66 nmol/liter x 0.33 Calcium, serum 8.5 -10.5 mg/dl 2.1-2.6 mmol/liter x 0.25 Calcium, urine 0-300 mg/24h 0.0-7.5 mmol/24h x 0.025 Cholesterol, total Desirable Marginal High 239 mg/dL 6.18 mmol/liter x 0.02586 Cholesterol, LDL Desirable Marginal High Very High 190 mg/dL 4.91 mmol/liter x 0.02586 Cholesterol, HDL Desirable Moderate Low (heart risk) >60 mg/dL 40-60 mg/dL >1.55 mmol/liter 1.03-1.55 mmol/liter x 0.02586 Cortisol: serum 0-25 µg/dl (depends on time of day) 0-690 nmol/liter x 27.59 Cortisol: free (urine) 20-70 µg/dl 55-193 nmol/24h x 2.759 Creatine kinase W 40-150 units/liter M 60-400 units/liter W 0.67-2.50 µkat/liter M 1.00-6.67 µkat/liter x 0.01667 DHEA W 130-980 ng/dl M 180-1250 ng/dl W 4.5-34.0 nmol/liter M 6.24-43.3 nmol/liter x 0.03467 DHEA Sulfate W Pre-menopause: 12-535 µg/dl W Post-menopause: 30-260 µg/dl M 10-619 µg/dl W Pre-menopause: 120-5350 µg/liter W Post-menopause: 300-2600 µg/liter M 100-6190 µg/liter x 10 Eosinophils 0-8% of white blood cells 0.0-0.8 fraction of white blood cells x 0.01 Erythrocyte sedimentation rate (Sed Rate) W<=30 mm/h M<=20 mm/h W<=30 mm/h M<=20 mm/h No conversion Folate 3.1-17.5 ng/ml 7.0-39.7 nmol/liter x 2.266 Glucose, urine <0.05 g/dl <0.003 mmol/litro x 0.05551 Glucose, plasma 70-110 mg/dl 3.9-6.1 mmol/liter x 0.05551 GGT (Gamma glutamyl transferase) W <=45U/L M <=65 U/L W <=45U/L M <=65 U/L No conversion Hematocrit W 36.0% – 46.0% of red blood cells M 37.0% – 49.0% of red blood cells W 0.36-0.46 fraction of red blood cells M 0.37-0.49 fraction of red blood cells x 0.01 Hemoglobin W 12.0-16.0 g/dl M 13.0-18.0 g/dl W 7.4-9.9 mmol/liter M 8.1-11.2 mmol/liter x 0.6206 LDH (Lactate dehydrogenase) (total) <=270 U/L <=4.5 µkat/liter x 0.016667 Lactic acid 0.5-2.2 mmol/liter 0.5-2.2 mmol/liter No conversion Leukocytes (WBC) 4.5-11.0×103/mm3 4.5-11.0×109/liter No conversion Lymphocytes 16%-46% of white blood cells 0.16-0.46 fraction of white blood cells x 0.01 Mean corpuscular hemoglobin (MCH) 25.0-35.0 pg/cell 25.0-35.0 pg/cell No conversion Mean corpuscular hemoglobin concentration (MCHC) 31.0-37.0 g/dl 310-370 g/liter x 10 MCV (Mean corpuscular volume) W 78-102 µm3 M 78-100 µm3 W 78-102 fl M 78-100 fl No conversion Monocytes 4-11% of white blood cells 0.04-0.11 fraction of white blood cells x 0.01 Neutrophils 45%-75% of white blood cells 0.45-0.75 fraction of white blood cells x 0.01 Phosphorus 2.5 – 4.5 mg/dL 0.81-1.45 mmol/L x 0.323 Platelets (Thrombocytes) 130 – 400 x 10 3µL 130 – 400 x 10 9L No conversion Potassium 3.4-5.0 mmol/liter 3.4-5.0 mmol/liter No conversion RBC (Red blood cell count) W 3.9 – 5.2 x 106/µL3 M 4.4 – 5.8 x 10 6/µL3 W 3.9 – 5.2 x 1012/L M 4.4 – 5.8 x 10 12/L No conversion Sodium 135-145 mmol/liter 135-145 mmol/liter No conversion Testosterone, total (morning sample) W 6-86 ng/dl M 270-1070 ng/dl W 0.21-2.98 nmol/liter M 9.36-37.10 nmol/liter x 0.03467 Testosterone, free Age 20-40 Age 41-60 Age 61-80 W 0.6-3.1, M 15.0-40.0 pg/ml W 0.4-2.5, M 13.0-35.0 pg/ml W 0.2-2.0, M 12.0-28.0 pg/ml W 20.8-107.5, M 520-1387 pmol/liter W 13.9-86.7, M 451-1213 pmol/liter W 6.9-69.3, M 416-971 pmol/liter x 34.67 Triglicerides (fasting) Normal Borderline High Very high 40-150 mg/dl 150-200 mg/dl 200-500 mg/dl >500 mg/dl 0.45-1.69 mmol/liter 1.69-2.26 mmol/liter 2.26-5.65 mmol/liter >5.65 mmol/liter x 0.01129 Urea, plasma (BUN) 8-25 mg/dl 2.9-8.9 mmol/liter x 0.357 Urinalysis – pH Specific gravity 5.0-9.0 1.001-1.035 5.0-9.0 1.001-1.035 No conversion WBC (White blood cells, leukocytes) 4.5-11.0×10 3 /mm 3 4.5-11.0×10 9 liter No conversion TERMINOLOGY: UNITS: gram : common measurement of weight. Used in this table: pg (picograms), g (grams), mg (milligrams), etc. per liter katal (kat) : a unit of catalytic activity, used especially in the chemistry of enzymes. Used in this table: µkat (microkatals), nkat (nanokatals) per liter micrometer (µm) : a unit of length. Mean Corpuscular Volume is expressed in cubic micrometers mole :

WHAT IS ZIDOVUDINE? WHO SHOULD TAKE ZIDOVUDINE? WHAT ABOUT DRUG RESISTANCE? HOW IS ZIDOVUDINE TAKEN? WHAT ARE THE SIDE EFFECTS? HOW DOES ZIDOVUDINE REACT WITH OTHER DRUGS? WHAT IS ZIDOVUDINE? Zidovudine (Retrovir®, AZT) is a drug used for antiretroviral therapy (ART). It was first manufactured by GlaxoSmithKline. Glaxo’s patent on zidovudine expired in 2005. Generic versions made by Aurobindo, Ranbaxy and Roxane were approved in 2005. Zidovudine is also known as azido-deoxythymidine, zidovudine or ZDV. Zidovudine was the first drug approved for the treatment of HIV. It is a nucleoside analog reverse transcriptase inhibitor, or nuke. These drugs block the reverse transcriptase enzyme. This enzyme changes HIV’s genetic material (RNA) into the form of DNA. This has to occur before HIV’s genetic code gets inserted into an infected cell’s own genetic codes. WHO SHOULD TAKE ZIDOVUDINE? Zidovudine was approved in 1987 as an antiretroviral (ARV) drug for people with HIV infection. Recommended dosages are available for children over 6 weeks old. There are no absolute rules about when to start ART. You and your health care provider should consider your CD4 cell count, your viral load, any symptoms you are having, and your attitude about taking HIV medications. Fact Sheet 404 has more information about guidelines for the use of ART. If you take zidovudine with other ARV drugs, you can reduce your viral load to extremely low levels, and increase your CD4 cell counts. This should mean staying healthier longer. Because zidovudine was the first ARV approved, it has been studied more than any other drug. New drugs have been tested by comparing them to zidovudine. “Early treatment” with zidovudine was tested in people with no symptoms of HIV disease. The study showed no benefit to taking zidovudine. But zidovudine is used as part of combination therapy for people who are exposed to HIV through a workplace accident (needle stick or splash). Zidovudine greatly reduces transmission of HIV from the mother to her child. It is given to HIV-positive pregnant women from the 4th month of pregnancy until their baby is born, and to the newborn baby for 6 weeks. WHAT ABOUT DRUG RESISTANCE? Many new copies of HIV are mutations. They are slightly different from the original virus. Some mutations can keep multiplying even when you are taking an ARV drug. When this happens, the drug will stop working. This is called “developing resistance” to the drug. See Fact Sheet 126 for more information on resistance. Sometimes, if your virus develops resistance to one drug, it will also have resistance to other ARVs. This is called “cross-resistance”. Resistance can develop quickly. It is very important to take ARVs according to instructions, on schedule, and not to skip or reduce doses. HOW IS ZIDOVUDINE TAKEN? The recommended dose of zidovudine for adults is 500mg to 600mg daily. Zidovudine comes in 100mg capsules and 300mg tablets. It is also available in liquid form. Zidovudine is also available in Combivir and Trizivir. Combivir contains zidovudine and lamivudine. Trizivir contains zidovudine, lamivudine, and abacavir. For more information, see Fact Sheet 417 on Combivir or Fact Sheet 418 on Trizivir. WHAT ARE THE SIDE EFFECTS? When you start ART, you may have temporary side effects such as headaches, high blood pressure, or a general sense of feeling ill. These side effects usually get better or disappear over time. Some patients taking zidovudine continue to have nausea, vomiting, headaches and fatigue. The most serious side effects of zidovudine are anemia, myopathy and neutropenia. These side effects are not common. Anemia is a shortage of red blood cells caused by damage to bone marrow. If you get anemia, your health care provider might reduce your dose or switch zidovudine for another ARV. If the anemia is severe and you have to keep taking zidovudine, you may need a blood transfusion, or you might take the drug erythropoietin. For more information on anemia, see Fact Sheet 552. Myopathy is muscle pain and weakness. There is no specific treatment for myopathy. Neutropenia is an abnormally low number of neutrophils, the most common type of white blood cell. Neutropenia increases the risk of bacterial and fungal infections. HOW DOES ZIDOVUDINE REACT WITH OTHER DRUGS? Zidovudine can interact with other drugs or supplements you are taking. These interactions can change the amount of each drug in your bloodstream and cause an under- or overdose. New interactions are constantly being identified. Make sure that your health care provider knows about ALL drugs and supplements you are taking. Zidovudine should not be combined with stavudine (Zerit®, d4T). Zidovudine’s side effects may be worse if taken with several other drugs. Methadone may increase blood levels of zidovudine. If you take zidovudine and methadone, watch for zidovudine side effects. source: The AIDS Infonet

THE COMPLETE BLOOD COUNT (CBC) RED BLOOD CELL TESTS WHITE BLOOD CELL TESTS THE COMPLETE BLOOD COUNT (CBC) The most common laboratory test is the complete blood count (CBC). It examines the components of blood, including red and white blood cells and platelets. Most test results are reported as amounts in a sample of blood (for example, cells per milliliter) or as a percentage. Other laboratory tests are discussed in Fact Sheet 122 and Fact Sheet 123. All blood cells are made in the bone marrow, the center of large bones. Some medications or diseases can damage the bone marrow. This can reduce the numbers of different types of red or white blood cells. Every laboratory has its own "reference range" or normal values for the results of each test. Most lab reports show the normal range and highlight any test results outside the normal range. For more information on laboratory test results, see Fact Sheet 120 or Lab Tests online at https://www.labtestsonline.org/ RED BLOOD CELL TESTS Red blood cells carry oxygen from the lungs to cells throughout the body. This is measured by three main tests. The Red Blood Cell Count (RBC) is the total number of red blood cells. Hemoglobin (HGB) is a protein in red blood cells that actually carries oxygen from the lungs to the rest of the body. Hematocrit (HCT) measures the percentage of blood volume taken up by red blood cells. A high RBC is common for people who live at high altitude. It’s a way the body adjusts to thinner oxygen. Very low readings for RBC, hemoglobin and hematocrit can indicate anemia. With anemia, the cells do not get enough oxygen to function normally. People with anemia feel tired all the time and might look pale. See Fact Sheet 551 for more information on fatigue and Fact Sheet 552 on anemia. Mean Corpuscular Volume (MCV) measures the average volume (size) of individual red blood cells. A low MCV means that the cells are smaller than normal. This is usually caused by an iron deficiency or chronic disease. A high MCV can be caused by HIV medications. This is not dangerous. However, a high MCV can indicate megaloblastic anemia, where red blood cells are large and pale. This is caused by a shortage of folic acid. While the MCV measures the average size of red blood cells, the RDW (Red Blood Cell Distribution Width) measures the range of red blood cell sizes. RDW can help diagnose anemia or some vitamin deficiencies. Mean Corpuscular Hemoglobin (MCH) and Mean Corpuscular Hemoglobin Concentration (MCHC) measure the amount and concentration of hemoglobin in the average cell. The MCH is calculated by dividing total hemoglobin by the total number of red blood cells. Platelets (PT) help stop bleeding by forming clots and scabs. If you don’t have enough platelets, you might get internal bleeding or you could bruise easily. People with HIV disease sometimes have a low platelet count, also called "thrombocytopenia." Taking HIV medications usually corrects this problem. Platelets are almost never so high that they cause health problems. WHITE BLOOD CELL TESTS White blood cells (also called leukocytes) help fight infections in the body. White Blood Cell Count (WBC) is the total number of white blood cells. A high WBC usually means that the body is fighting an infection. A very low WBC can be caused by problems with the bone marrow. This condition, called cytopenia or leukopenia, means that your body is less able to fight off infections. The Differential counts five types of white blood cells: neutrophils, lymphocytes, monocytes, eosinophils and basophils. These are reported as a percentage of the WBC. The percentages are multiplied by the WBC to get "absolute" counts. For example, with 30% lymphocytes and a WBC of 10,000, the absolute lymphocyte count is 30% of 10,000, or 3,000. Neutrophils or polymorphonuclear cells (Polys) fight bacterial infections. They normally account for 55% to 70% of WBCs. If you have a very low count, you could get a bacterial infection. This condition is called neutropenia. Advanced HIV disease can cause neutropenia. So can some medications including ganciclovir, a drug used to treat cytomegalovirus (see Fact Sheet 504) and the anti-HIV drug AZT. There are two main types of lymphocytes (lymphs). "T cells" attack and kill germs, and help regulate the immune system. "B cells" make antibodies, special proteins that attack germs. Lymphocytes are normally 20% to 40% of WBCs. A regular CBC does not give T-cell counts. Most people with HIV infection get special T-cell tests (see Fact Sheet 124). However, the results of a CBC are needed to calculate T-cell counts, so both tests are done at the same time. Monocytes or Macrophages (Monos) make up 2% to 8% of WBCs. They fight infections by "eating" germs and telling the immune system what germs they have found. Monocytes circulate in the blood. When monocytes settle in various tissues they are called macrophages. A high count usually indicates a bacterial infection. Eosinophils (Eos) are normally 1% to 4% of WBCs. They are involved with allergies and reactions to parasites. Sometimes, HIV disease can cause a high eosinophil count. A high count, especially if you have diarrhea, gas or stomach bloating, may indicate the presence of parasites. Basophils (Bas) are not well understood, but they are involved in long-term allergic reactions such as asthma or skin allergies. They are usually less than 1% of WBCs. source: The AIDS Infonet

WHAT IS ANEMIA? WHAT CAUSES ANEMIA? ANEMIA AND HIV HOW IS ANEMIA TREATED? THE BOTTOM LINE WHAT IS ANEMIA? Anemia is a shortage of hemoglobin (HGB). HGB is a protein in red blood cells. It carries oxygen from the lungs to the rest of the body. Anemia causes fatigue, shortness of breath and dizziness. People with anemia don’t feel as good as people with a normal level of HGB. They find it harder to work. This is called having a lower quality of life. HGB levels are measured as part of a complete blood count (CBC). See Fact Sheet 121 for more information on these laboratory tests. HGB is measured as grams per deciliter, the amount in a specific sample of blood. Anemia is defined by the level of HGB. Most health care providers agree that HGB levels below 6.5 indicate life-threatening anemia. Normal levels are at least 12 for women and at least 14 for men. Overall, women have lower levels of HGB. So do very old and very young people. More African-Americans have anemia than people in other ethnic groups. WHAT CAUSES ANEMIA? The bone marrow produces red blood cells. This process requires iron, the vitamins B12 and folic acid (or folate.) Erythropoietin (EPO) stimulates the production of red blood cells. EPO is a hormone made by the kidneys. Anemia can be caused by the body not making enough red blood cells. It is also caused by their loss or destruction. Several factors can cause anemia: Too little iron, vitamin B12 or folate. A shortage of folate can cause megaloblastic anemia, where red blood cells are large and pale (see Fact Sheet 121) Damage to bone marrow or kidneys Blood loss from internal bleeding or a woman’s menstrual cycle Destruction of red blood cells (hemolytic anemia) HIV infection can cause anemia. So can many opportunistic infections (see fact sheet 500) related to HIV disease. Many drugs commonly used to treat HIV and related infections can cause anemia. ANEMIA AND HIV Serious anemia used to be much more common. Over 80% of people with an AIDS diagnosis had some degree of anemia. People with more advanced HIV disease, or a lower CD4 count, had higher rates of anemia. The rate of anemia went down when people started using combination antiretroviral therapy (ART). Severe anemia has become rare. However, ART has not eliminated anemia. A large study found that about 46% of patients had mild or moderate anemia, even after one year of ART. Several factors are linked to a higher rate of anemia in people with HIV: Lower CD4 cell counts (see fact sheet 124). Higher viral load (fact sheet 125) Taking AZT (Retrovir, fact sheet 411) Being African-American Being a woman HIV disease progression is about 5 times more common in people with anemia. Anemia is also linked to a higher risk of death. Treatment of anemia seems to eliminate these risks. HOW IS ANEMIA TREATED? Treating anemia depends on its cause. First, treat any chronic bleeding. This could be internal bleeding, hemorrhoids, or even frequent nosebleeds. Next, correct any shortages of iron, vitamin B12 or folate. Stop using, or reduce the doses of medications that cause anemia. These approaches might not work. It may not be possible to stop using all medications that cause anemia. Two additional treatments are injections of EPO, and blood transfusions. EPO (erythropoietin) stimulates the production of red blood cells. In 1985, scientists learned how to make synthetic EPO. It is injected under the skin, usually once a week. The most common brand of EPO is Procrit®. A large study of people with HIV found that EPO injections decreased the risk of death. Transfusions seemed to increase it. Because of the risks of transfusions, they are rarely used to treat anemia. Blood transfusion used to be the only treatment for severe anemia. However, transfusions can cause infection and suppress the immune system. They appear to cause faster progression of HIV disease and to increase the risk of death for HIV patients. THE BOTTOM LINE Anemia increases fatigue and makes people feel bad. It increases the risk of disease progression and death. It can be caused by HIV infection or other diseases. Many drugs used to treat HIV and related infections also cause anemia. Anemia has always been a problem for people with HIV and AIDS. The rate of serious anemia has dropped considerably since people started using ART. However, almost half of people with HIV still have mild or moderate anemia. Treating anemia improves the health and survival of people with HIV. Correcting bleeding or shortages of iron, or vitamins are the first steps. If possible, medications that cause anemia should be stopped. If necessary, the patient should be treated with erythropoietin, or, in rare cases, with a blood transfusion. source: The AIDS Infonet

WHAT IS THRUSH? CAN IT BE PREVENTED? HOW IS IT TREATED? NATURAL THERAPIES THE BOTTOM LINE WHAT IS THRUSH? Candidiasis is a common opportunistic infection in people with HIV. It is an infection caused by a common type of yeast (or fungus) called candida. This yeast is found in most people’s bodies. A healthy immune system keeps it under control. Candida usually infects the mouth, throat, or vagina. It can occur months or years before other, more serious opportunistic infections. See Fact Sheet 500 for more information on opportunistic infections. In the mouth, the infection is called thrush. When the infection spreads deeper into the throat it is called esophagitis. It looks like white patches similar to cottage cheese, or red spots. It can cause a sore throat, pain when swallowing, nausea, and loss of appetite. In the vagina, the infection is called yeast infection or vaginitis. This is a common vaginal infection. Symptoms include itching, burning, and a thick whitish discharge. Candida can also apread and cause infection in the brain, heart, joints, and eyes. CAN IT BE PREVENTED? There is no way to prevent exposure to candida. Medications are not normally used to prevent candidiasis. There are several reasons for this: It is not very dangerous There are effective drugs to treat it The yeast could develop resistance to the medications. Strengthening your immune system by taking combination antiretroviral therapy (ART) is the best way to prevent an outbreak of candidiasis. HOW IS IT TREATED? A healthy immune system keeps candida in balance. Bacteria normally found in the body also help control it. Some antibiotics kill these helpful bacteria and cause an outbreak of candidiasis. Treating candidiasis will not get rid of the yeast, but will keep it under control. Treatments can be local or systemic. Local treatments are applied where the infection is found. Systemic treatments affect the whole body. Many health care providers prefer to use local treatment first. It puts the medication directly where it is needed. It has fewer side effects than a systemic treatment. Also, there is less risk of candida becoming resistant to the medications. The medications used to fight candida are antifungal drugs. Almost all their names end in "-azole." They include clotrimazole, nystatin, fluconazole, and itraconazole. Local treatments include: creams suppositories to treat vaginitis liquids "troches" or "lozenges" that dissolve in the mouth Local treatments may cause some stinging or irritation. Systemic treatment is needed if local treatments don’t work, or if the infection has spread into the throat (esophagitis) o other parts of the body. Some systemic drugs are taken in pill form. The most common side effects are nausea, vomiting, and abdominal pain. Less than 20% of people have these side effects. Candidiasis can come back repeatedly. Some health care providers prescribe anti-fungal drugs on a long-term basis. This can cause resistance. The yeast can mutate so that a drug no longer works. Some serious cases do not respond to other medications. Then, amphotericin B might be used. It is a very potent and toxic drug, given orally or intravenously. The major side effects are kidney problems and anemia. Other reactions include fever, chills, nausea, vomiting, and headache. These usually get better after the first few doses. NATURAL THERAPIES Several non-drug therapies seem to help. They have not been carefully studied to prove that they work. Reduce the amount of sugar you eat. Drink Pau d’Arco tea. It is made from the bark of a South American tree. Take garlic supplements or eat raw garlic. Garlic has anti-fungal and anti-bacterial properties. However, it can interfere with protease inhibitor drugs. Gargle with tea tree oil diluted in water. Take lactobacillus (acidophilus) capsules or eat yogurt with this bacteria. Make sure the label says it has live, active cultures. It may help to take it after taking antibiotics. Take supplements of gamma-linoleic acid (GLA) and Biotin. They both seem to slow the spread of candida. GLA is found in several cold-pressed oils. Biotin is a B vitamin. THE BOTTOM LINE Candidiasis is a very common yeast (fungal) infection. The fungus normally lives in the body. It cannot be eliminated. The best way to avoid an outbreak of candidiasis is to strengthen your immune system by taking antiretroviral medications (ARVs). Most candida infections are easily treated with local therapies. In people with weakened immune systems, these infections become more persistent. Systemic anti-fungal drugs can be taken, but candida might become resistant to them. The most potent anti-fungal drug, amphotericin B, has serious side effects. Several natural therapies seem to help control candida infections. source: The AIDS Infonet

WHAT IS CMV? HOW IS CMV TREATED? CAN CMV BE PREVENTED? HOW DO I CHOOSE A TREATMENT FOR CMV? THE BOTTOM LINE WHAT IS CMV? Cytomegalovirus (CMV) is an opportunistic infection. The virus is very common. Between 50% and 85% of the US population tests positive for CMV by the time they are 40 years old. A healthy immune system keeps this virus in check. When the immune defenses are weak, CMV can attack several parts of the body. This can be caused by various diseases including HIV. Combination antiretriviral therapy (ART) has reduced the rate of CMV in people with HIV by 75%. However, about 5% of people with HIV still develop CMV disease. The most common illness caused by CMV is retinitis. This is the death of cells in the retinas, the back of the eye. It can quickly cause blindness unless treated. CMV can spread throughout the body and infect several organs at once. The risk of CMV is highest when CD4 cell counts are below 50. It is rare in people with more than 100 CD4 cells. The first signs of CMV retinitis are vision problems such as moving black spots. These are called "floaters." They may indicate an inflammation of the retina. Patients may also notice light flashes, decreased or distorted vision, or blind spots. Some doctors recommend eye exams to catch CMV retinitis. The exams are done by an ophthalmologist (an eye specialist.) If your CD4 count is below 100 and you experience any vision problems, tell your health care provider immediately. Some patients who have recently started using ART can get inflammation in their eyes, causing loss of vision. This is called immune restoration syndrome (See Fact Sheet 473). A recent study suggests that having active CMV makes it eaier to pass HIV to others. HOW IS CMV TREATED? The first treatments for CMV required daily intravenous infusions. Most people had a permanent medication ?port? inserted into their chest or arm. People had to keep taking anti-CMV drugs for life. CMV treatments have improved dramatically over the past several years. There are now seven CMV treatments approved by the FDA. Strong antiretroviral medications (ARVs) can improve the immune system. Patients can stop taking CMV drugs if their CD4 cell count goes over 100 to 150 and stays there for at least three months. However, there are two special cases: Immune restoration syndrome can cause severe inflammation in the eyes of people with HIV even if they didn?t have CMV before. The usual treatment is to add anti-CMV drugs to the patient’s ART. If the CD4 count drops below 50, there is an increased risk of developing CMV disease. CAN CMV BE PREVENTED? Ganciclovir was approved for prevention (prophylaxis) of CMV. However, many health care providers don’t prescribe it. They don’t want to add up to 12 capsules a day for their patients. Also, it’s not clear that it does any good. Two large studies came to different conclusions. Finally, strong ARVs keep most people’s CD4 counts high enough so that they won’t get CMV. HOW DO I CHOOSE A TREATMENT FOR CMV? There are several issues to consider when choosing a treatment for active CMV disease: Is your vision at risk? You may need to take quick action to save your eyesight. How effective is it? Intravenous ganciclovir is the most effective overall CMV treatment. Implants are very good at stopping retinitis. However, they only work in the eye with the implant. How is it administered? Pills are the easiest to manage. Intravenous (IV) medication involves needle sticks or a medication line that might become infected. Ocular injections mean inserting a needle directly into the eye. Implants, which last six to eight months, take about an hour to insert in an office procedure. Is it a local therapy or systemic? Local therapies affect just the eyes. CMV retinitis can progress rapidly and lead to blindness. For this reason, it is treated aggressively when it first shows up. The newer injections or implants put medication directly into the eye and have the greatest impact on retinitis. CMV can also show up in other places in the body. To control CMV in the rest of the body, you need a systemic (whole-body) therapy. Intravenous medication or valganciclovir pills can be used. What are the side effects? Some CMV drugs can damage your bone marrow or kidneys. This may require additional medications. Other drugs require infusions that can take a long time. Discuss the side effects of any CMV treatment with your health care provider. What do the guidelines say? Recently, several sets of professional guidelines have recommended valganciclovir as the preferred treatment for patients who are not at immediate risk of losing their sight. THE BOTTOM LINE Strong ARVs are probably the best way to prevent CMV. If your CD4 cell count is below 100, talk with your health care provider about CMV prevention and a regular schedule of eye exams. If you have a low CD4 cell count and experience ANY unusual vision problems, see your health care provider immediately! Treatments directly in the eye make it possible to control CMV retinitis. With the newer drugs to treat CMV, you can avoid implanted medication lines and daily infusions. Most people can safely stop taking CMV medication if their CD4 cell counts go up and stay above 100 to 150 when they take anti-HIV drugs. source: The AIDS Infonet

WHAT IS KS? HOW IS KS TREATED? CAN KS BE PREVENTED? WHAT ELSE IS BEING STUDIED FOR KS? THE BOTTOM LINE WHAT IS KS? Kaposi’s sarcoma (KS) is a cancer-like disease. It originally was known as a disease affecting elderly men of Eastern European or Mediterranean background. KS also occurs in African men and people with a weakened immune system. The most common cause of KS now is HIV infection. KS usually shows up in the skin, or in the linings of the mouth, nose, or eye. KS can also spread to the lungs, liver, stomach and intestines, and lymph nodes. KS involves the development of many new, tiny blood vessels. This process is called angiogenesis. KS is caused by a herpes virus called Human Herpes Virus 8 (HHV-8). In a recent study, men with HHV-8 were nearly 12 times more likely to be diagnosed with KS than men who did not have HHV-8. KS affects about 20% of people with AIDS who aren’t taking anti-HIV drugs. The rate of KS has dropped by oer 80% since the introduction of strong antiretroviral therapy (ART). KS is mostly a disease of men: there are at least 8 men with KS for each woman. It is one of the most visible signs of AIDS, because it usually shows up as spots on the skin (lesions) that look red or purple on white skin, and bluish, brownish or black on dark skin. Lesions often occur on the face, arms and legs. KS on the skin is not life threatening. However, KS lesions on the feet and legs can make it difficult to walk. If KS spreads to other parts of the body, it can cause serious problems. In the mouth lining, it can cause trouble eating and swallowing. In the stomach or gut, it can cause internal bleeding and blockages. If KS blocks lymph nodes, it can cause severe swelling of the arms, legs, face, or scrotum. The most serious form of KS is in the lungs, where it can cause a serious cough, shortness of breath, or an accumulation of fluid that can be fatal. KS can often be diagnosed by looking at the skin lesions. They are usually flat, painless, and do not itch or drain. They can look like a bruise, but a bruise will lose its purple color if you push on it; a KS lesion won’t. KS lesions can grow into raised bumps or patches and grow together. Your health care provider might take a small sample (a biopsy) from skin spots to examine under a microscope and confirm a diagnosis of KS. HOW IS KS TREATED? Strong ART is the best treatment for active KS. In many people, ART can stop the growth or even clear up skin lesions. In addition to ART, there are different treatments for KS in the skin or in other parts of the body. In the skin, KS may not have to be treated if there are only a few lesions. Skin lesions can be: Frozen with liquid nitrogen, Treated with radiation, Cut out surgically, Injected with anti-cancer drugs or interferon alpha. Treated with Panretin gel (retinoic acid) These treatments only deal with the skin lesions, not with KS overall. Skin lesions may come back after treatment. If KS has spread into internal organs, into internal organs, systemic (whole-body) drug treatment is used. If ART is not enough, the drugs doxorubicin (Doxil®,) daunorubicin (DaunoXome®) or paclitaxel (Taxol®) may be added. Doxil and DaunoXome are anti-cancer drugs in "liposomal" form. "Liposomal" means that tiny amounts of drug are encased in small fat bubbles (liposomes). The drugs last longer in this form and seem to move to the areas where they’re needed. Some side effects are reduced with liposomal forms of drugs. CAN KS BE PREVENTED? It is not clear how HHV-8 spreads. It might be spread through sexual activity and deep kissing. As with other opportunistic infections, a healthy immune system can control HHV-8 infection. The best way to prevent KS is by using strong anti-HIV medications to keep your immune system strong. WHAT ELSE IS BEING STUDIED FOR KS? Anti-cytokine approaches: There is a lot of research on cytokines, proteins that the immune system uses to sti mulate cells to grow. Researchers think that substances that can inhibit these (and similar) growth factors can also slow down the growth of KS. Monoclonal antibodies: These drugs are produced through genetic engineering. Their names end in "-mab," such as bevacizumab. Other drugs: Scientists are studying several drugs that slow down the development of new blood vessels (angiogenesis.) THE BOTTOM LINE KS is a disease that affects up to 20% of people with AIDS who are not taking ART. It is partly caused by a herpes virus called HHV-8. The best treatment for KS is strong antiretroviral therapy (ART.) KS in the skin can be treated in several ways and is not a serious problem. KS in internal organs can be life threatening. Internal KS is usually treated with anti-cancer drugs. If you notice new dark spots on your skin, have your health care provider look at them to see if you might have KS. source: The AIDS Infonet

WHAT IS ATOVAQUONE? WHAT IS PCP? WHAT IS TOXOPLASMOSIS? HOW IS ATOVAQUONE USED? WHAT ARE THE SIDE EFFECTS? HOW DOES ATOVAQUONE INTERACT WITH OTHER DRUGS? THE BOTTOM LINE WHAT IS ATOVAQUONE? Atovaquone is an antibiotic. Sometimes it is prescribed to treat pneumocystis pneumonia (PCP, see Fact Sheet 515). It is also sometimes used to treat toxoplasmosis (See Fact Sheet 517). Atovaquone can be given to prevent PCP or toxoplasmosis. It is also given in cases where a patient is allergic to Sulfa drugs (Bactrim or Septra) or Dapsone, or when other therapies have been ineffective. Atovaquone is as effective as more commonly-prescribed drugs. It has fewer and different side effects. However, it is very expensive. Because of its cost, it is usually only considered for people who cannot tolerate TMP/SMX or dapsone. Combination antiretroviral therapy (ART) can make your CD4 cell count go up. If it goes over 200 and stays there for 3 months, it may be safe to stop taking PCP medications such as atovaquone. Talk to your health care provider before discontinuing any medication. WHAT IS PCP? PCP (or pneumocystis pneumonia) is the most common opportunistic infection in people with HIV. Without treatment, over 85% of people with HIV would eventually develop PCP. It has been the major killer of people with HIV. PCP is now almost entirely preventable and treatable. Unfortunately, PCP is still common in people who are infected with HIV for a long time before getting treatment. In fact, 30% to 40% of people with HIV have PCP if they wait to get treatment until their CD4 cell counts (see Fact Sheet 124) are around 50. Fact Sheet 515 has more information about PCP. PCP is caused by a fungus. A healthy immune system can control the fungus. However, when the immune system is weak or damaged, PCP causes illness in children and in adults. Pneumocystis almost always affects the lungs, causing a form of pneumonia. People with CD4 cell counts under 200 have the highest risk of developing PCP. People with counts under 300 who have already had another opportunistic infection are also at risk. Most people who get PCP become much weaker, lose a lot of weight, and are likely to get PCP again. The first signs of PCP are difficulty breathing, fever, and a dry cough. Anyone with these symptoms should see a doctor immediately. However, everyone with CD4 counts below 300 should discuss PCP prevention with their doctor, before they experience any symptoms. WHAT IS TOXOPLASMOSIS? Toxoplasmosis (toxo) is an infection caused by the parasite Toxoplasma gondii. Protozoa are single-celled animals. A parasite lives inside another living organism (the host) and takes all of its nutrients from the host. See Fact Sheet 517 for more information on Toxoplasmosis. Up to 60 million Americans are infected with toxo. A healthy immune system will keep toxo from causing any disease. However, a weakened immune system cannot always keep toxo in check. It does not seem to spread from person to person. Pregnant women who are exposed to toxo may pass it to their newborn child. The most common illness caused by toxo is an infection of the brain (encephalitis). Toxo can also infect other parts of the body. Toxo can lead to coma and death. The risk of toxo is highest when your CD4 cell counts are below 100. The first signs of toxo include fever, confusion, headache, disorientation, personality changes, tremor, and seizures. Toxo is usually diagnosed by a brain scan such as a CAT or MRI scan. If the brain scan shows changes that might be due to toxo, then a blood test can help to confirm the diagnosis. The blood test is also helpful to see if you have been exposed to toxo in the past and might benefit from prophylaxis against toxo; that is, taking medications to prevent toxo. HOW IS ATOVAQUONE USED? Atovaquone is not the first choice for treatment of PCP or toxo. However, your doctor may decide to use it if you have certain allergies or bad side effects. Your doctor will recommend a specific dosage. WHAT ARE THE SIDE EFFECTS? The most common side effects of atovaquone are fever and skin rash. Other side effects may occur that usually don’t require medical attention. However, if they become severe, talk to your health care provider. These include cough, diarrhea, headache, nausea, vomiting, and trouble sleeping. HOW DOES ATOVAQUONE INTERACT WITH OTHER DRUGS? Atovaquone can interact with rifampin (Rifadin®), a drug used to treat tuberculosis. The interaction decreases the amount of atovaquone in the blood. This may also occur with a related drug, rifabutin. It is also used to treat tuberculosis. THE BOTTOM LINE Atovaquone is used to treat PCP and toxoplasmosis. It can prevent new infections or treat active infections. Atovaquone is not the first choice for these situations. Therefore it is normally used only when other drugs have failed or cannot be used. If your CD4 cell count is below 300, talk to your doctor about taking drugs to prevent PCP. Everyone whose CD4 cell count is below 200 should be taking anti-PCP medication. source: The AIDS Infonet

WHAT IS PENTAMIDINE? WHAT IS PCP? HOW IS PENTAMIDINE USED? WHAT ARE THE SIDE EFFECTS? HOW DOES PENTAMIDINE INTERACT WITH OTHER DRUGS? THE BOTTOM LINE WHAT IS PENTAMIDINE? Pentamidine (sold as NebuPent®, Pentam®, and Pentacarinat®) is a treatment for pneumocystis pneumonia (PCP). See Fact Sheet 515 for more information on PCP. Pentamidine is normally not the first choice for treatment of PCP. However, it is used for patients who are allergic to sulfa drugs or dapsone. It may also be used when other drugs have not worked. Pentamidine is a drug that is usually inhaled in an aerosol form to prevent PCP. Pentamidine is also used intravenously (IV) to treat active PCP. WHAT IS PCP?? PCP (or pneumocystis pneumonia) is the most common opportunistic infection in people with HIV. Without treatment, over 85% of people with HIV would eventually develop PCP. It has been the major killer of people with HIV. However, PCP is now almost entirely preventable and treatable. Unfortunately, PCP is still common in people who are infected with HIV for a long time before getting treatment. In fact, 30% to 40% of people with HIV have PCP if they wait to get treatment until their CD4 cell counts (see Fact Sheet 124) are around 50. For more information about PCP, see Fact Sheet 515. PCP is caused by a fungus. A healthy immune system can control the fungus. However, PCP causes illness in children and in adults with a weakened immune system. The fungs that causes PCP almost always affects the lungs, causing a form of pneumonia. People with CD4 cell counts under 200 have the highest risk of developing PCP. People with counts under 300 who have already had another opportunistic infection are also at risk. Most people who get PCP become much weaker, lose a lot of weight, and are likely to get PCP again. The first signs of PCP are difficulty breathing, fever, and a dry cough. Anyone with these symptoms should see a health care provider immediately. However, everyone with CD4 counts below 300 should discuss PCP prevention with their health care provider, before they experience any symptoms. Bactrim or Septra (TMP/SMX) is normally the most effective drug against PCP. It is also inexpensive, costing only about $10 per month. However, the "SMX" part is a sulfa drug and almost half of the people who take it have an allergic reaction. Dapsone causes fewer allergic reactions than TMP/SMX. It is also fairly inexpensive – about $30 per month. It also is taken as a pill and, like Bactrim or Septra, not more than one pill daily. HOW IS PENTAMIDINE USED? For prevention of PCP, pentamidine is administered with a nebulizer. This is a machine that produces a very fine mist of the drug. Some people must go to a clinic to get nebulizer treatments. Others can have a nebulizer at home. The mist is inhaled directly into the lungs. The procedure takes about 30 to 45 minutes. You pay for the drug plus the clinic costs, between $120 and $250 per month. Patients using aerosol pentamidine get PCP more often than people taking the antibiotic pills. For treatment of PCP, pentamidine is also available for injection. In this form, it is usually used once a day for 14 days or longer. It may also be used as an intravenous (IV) injection. WHAT ARE THE SIDE EFFECTS? Let your health care provider know right away if you have difficulty breathing, dizziness, chest pain or tightness, cough, headache, or weakness. Other side effects usually don’t require medical attention unless they get serious. These include changes in how things taste, nausea, or vomiting. When pentamidine is given intravenously, it can cause low levels of white and red blood cells. It can also lower the number of platelets in the blood, which affect blood clotting. Intravenous pentamidine may also cause several serious side effects, including: Very high or low blood sugar Problems with the pancreas, liver or kidneys High levels of potassium in the blood Irregular heart rhythm Report any side effects or changes in your condition to your health care provider immediately to avoid serious conditions. If you are pregnant, talk to your health care provider before taking any form of pentamidine. HOW DOES PENTAMIDINE INTERACT WITH OTHER DRUGS? You may need to stop taking ddI (see FactSheet 413) when you take pentamidine. THE BOTTOM LINE When the first-choice treatments for pneumocystis pneumonia cannot be used, pentamidine can be used. It can be used to prevent new PCP infections or to treat active infections. It comes in various forms. It can interact with many HIV medications, and can also have many serious side effects. If your CD4 cell count is below 300, talk to your health care provider about taking drugs to prevent PCP. Everyone whose CD4 cell count is below 200 should be taking anti-PCP medication. source: The AIDS Infonet

WHAT IS DAPSONE? WHY DO PEOPLE WITH HIV TAKE DAPSONE? WHAT ABOUT DRUG RESISTANCE? HOW IS DAPSONE TAKEN? WHAT ARE THE SIDE EFFECTS? HOW DOES DAPSONE REACT WITH OTHER DRUGS? WHAT IS DAPSONE? Dapsone is an antibiotic drug. It is sold as Dapsone or Avlosulfon®. Antibiotics fight infections caused by bacteria. Dapsone is also used to fight opportunistic infections in people with HIV. Jacobus manufactures it. WHY DO PEOPLE WITH HIV TAKE DAPSONE? Dapsone is usually used to fight leprosy or a skin problem called dermatitis herpetiformis. Many germs live in our bodies or are common in our surroundings. A healthy immune system can fight them off or keep them under control. However, HIV infection can weaken the immune system. Infections that take advantage of weakened immune defenses are called "opportunistic infections." People with advanced HIV disease can get opportunistic infections. See Fact Sheet 500 for more information on opportunistic infections. One opportunistic infection in people with HIV is PCP. This stands for pneumocystis jiroveci pneumonia, which affects the lungs. See Fact Sheet 512 for more information on PCP. People who have a CD4 cell count of less than 200 may develop PCP. Health care providers sometimes use a combination of trimethoprim (see fact sheet 535) and dapsone to treat PCP. Dapsone can also be used to prevent PCP. If your CD4 cell count is below 200, ask your health care provider if you should be taking dapsone or another drug to prevent PCP. Another opportunistic infection is toxoplasmosis (toxo), which affects the brain. See Fact Sheet 517 for more information on toxo. People who have a CD4-cell count of less than 100 may develop toxo. Dapsone can be used with the drug pyrimethamine to treat cases of toxo. This combination can also be used to prevent toxo. Who should not take dapsone: Some people are allergic to dapsone. Be sure to tell your health care provider if you are allergic to any antibiotics. Dapsone can cause anemia. People who are anemic should talk to their health care provider about whether dapsone is the best drug for them. Some people have low levels of an enzyme known as glucose-6-phosphate dehydrogenase or G6PD. Up to 15% of African-American men, and many men of Mediterranean ancestry have this shortage and should not take dapsone. They could develop sudden, severe anemia. Taking dapsone during pregnancy may increase the risk of birth defects. Women who are pregnant or breastfeeding women should avoid taking it if possible. WHAT ABOUT DRUG RESISTANCE? Whenever you take medication, be sure to take all of the prescribed doses. Many people stop if they feel better. This is not a good idea. If the drug doesn’t kill all of the germs, they might change (mutate) so that they can survive even when you are taking medications. When this happens, the drug will stop working. This is called "developing resistance" to the drug. For example, if you are taking dapsone to fight PCP and you miss too many doses, the PCP in your body could develop resistance to dapsone. Then you would have to take a different drug or combination of drugs to fight it. HOW IS DAPSONE TAKEN? Dapsone is available in tablets of 25 or 100 milligrams (mg.) It is normally taken once a day or three times a week. The dose you take depends on the type of infection you are trying to treat or prevent. The treatment continues as long as your CD4 cell count is low enough for you to develop toxo or PCP. Dapsone can be taken with or without food. If your stomach gets upset when you take dapsone, take it with food. WHAT ARE THE SIDE EFFECTS? The main side effect of dapsone is anemia, a loss of red blood cells. Stomach upset is also common. A few people get nausea, leg or back pain, vomiting, headache, dizziness, or peripheral neuropathy (see fact sheet 555 on peripheral neuropathy). Dapsone can make you sensitive to sunlight. If this occurs, use sun block on your skin and/or wear sunglasses. Tell your health care provider if your skin gets pale or yellowish, or you get a sore throat, fever, or rash, even after a few weeks of taking dapsone. These might indicate a serious drug reaction. HOW DOES DAPSONE REACT WITH OTHER DRUGS? Dapsone is broken down by the liver. It can interact with other drugs that also use the liver. Scientists have not yet studied all the possible interactions. Dapsone probably interacts with some blood thinners, heart medications, seizure medications, and other antibiotics. Be sure your health care provider knows about all the medications you are taking. Your health care provider should watch carefully for drug interactions if you are taking dapsone along with the protease inhibitors amprenavir (Ziagen®) or saquinavir (Invirase®), or the non-nucleoside reverse transcriptase inhibitor delavirdine (Rescriptor®). Blood levels of dapsone can be reduced if you take rifampin, a drug used to treat tuberculosis (see fact sheet 518) or MAC (see fact sheet 514) . Also, ddI can reduce absorption of dapsone. Take dapsone at least 2 hours before or after you take ddI. The risk of developing anemia is higher if you take dapsone at the same time as other drugs that can cause anemia, such as AZT (Retrovir, see fact sheet 411). The risk of developing peripheral neuropathy is higher if you take dapsone at the same time as other drugs that can cause neuropathy, such as ddI and d4T (See fact sheets 413 and 414). source: The AIDS Infonet