NOTES FROM THE UNDERGROUND
The PWA Health Group Newsletter
"Access to Information Precedes Access to Treatment"
Winter 1998-99 Issue 38

Table of Contents

Glutamania: Wonder Substance?
HIV Medications + Street Drugs
Pain Medications and Recovery
Hepatitis TX Update

Glutamania! Is There Anything Glutamine Doesn t Do?  by Maia Szalavitz

It slices, it dices, it's a floor wax, it's a whipped topping -- the literature on glutamine, the body's most abundant amino acid can put one in mind of those late night infommercials touting miracle products. Glutamine has been reported to stop diarrhea and wasting, build lean body mass and improve muscle definition, promote immune cell growth and even possibly slow progression of HIV disease.

Glutamine is known as a crucial chemical for muscles. Glutamine is also used by immune cells and enterocytes (intestinal cells) for energy, it's important to the liver, the kidney and the brain.

But unfortunately, just as in those infommercials, there is very little solid data to prove that this nutritional supplement can actually help people with HIV live longer and better lives. There are some tantalizing clues however, and since it has very few reported side effects and very little potential toxicity, many people have decided to try it, usually in combination with antioxidant supplements like beta-carotene, NAC (n-acetyl cysteine), thioctic acid (alpha-lipoic acid), selenium and Vitamins C and E.

Here's the reasoning behind anti-oxidant use. In HIV, and other chronic illnesses, free radicals tend to build up in the bloodstream as a result of the way the immune system attacks its enemies. These nasty chemicals lack an outer electron. They damage the body by stealing electrons from healthy cells and lessen the body's ability to repair itself. One of the primary anti-oxidants needed to reduce this oxidative stress is a substance called glutathione

And you guessed it glutamine is one of its precursors, as is NAC.

Normally, nutrition provides enough anti-oxidants to combat this oxidative stress and neutralize the free radicals . But under continuous siege by HIV, the need for anti-oxidants begins to grow beyond what a regular diet can provide. Wasting is one result muscle tissue is rich in glutamine. The body starts breaking down muscle to fight the oxidative stress . Another result is a higher viral load, because HIV thrives in an environment rich in free radicals. Some nutritionists have begun to call glutamine a conditionally essential nutrient.

A recent study of about 100 PWAs, mostly men with less than 200 T-cells, done by Drs. Leonore and Leonard Herzenberg at Stanford University, found that glutathione levels are directly linked to survival. 85% of those who started the study with high glutathione levels survived the three-year-long study while only 18% with low levels did. It isn t known whether low glutathione levels cause or quicken disease progression or if they are a symptom of some other process however supplementation to increase glutathione levels in cells is increasingly popular. Glutathione is also crucial for liver health.

Some recent studies have suggested that taking glutathione itself can raise the glutathione levels in immune cells, but according to Dr. Judy Shabert of the Harvard University School of Medicine, the extra expense of doing so is unwarranted. Glutathione is taken up by the intestines, but it's broken down by the liver, so it's really just a very expensive source of cysteine. Our research has found that glutamine really does make glutathione and it has the advantage of doing many other things.

A recent study in the Lancet, for example, reported that glutamine supplementation significantly decreased the incidence of pneumonia, and other life-threatening infections like bacteremia and septicemia, for patients with multiple traumas and who were being fed intravenously. In the study, only 17% of patients on glutamine got pneumonia, compared to 45% of the participants who were not on glutamine. 7% on glutamine contracted bacteremia, while 42% of the non-glutamine group did. Finally, 3% (one person!) of those in the glutamine group experienced sepsis, compared to 26% of the non-glutamine group.

The effect of glutamine on the gut is pretty well documented because supplementation has been found useful not only for people with HIV, but with other conditions that require intravenous feeding like severe burns and intestinal surgery.

A pilot double-blind study of glutamine for intestinal problems in PWAs did not produce statistically significant results, quite possibly because the highest dose used was only 8 grams and most researchers now recommend doses higher than 20 grams for acute problems. However, it did show a trend towards improvement in those on higher doses. Studies of people with other conditions have found that glutamine supplementation speeds recovery and can even restore firm, healthy stools to people who have only inches (of a former 21 feet!) of intestine remaining.

Most people think the intestine is just an organ needed for the elimination of waste, but in fact, it is a crucial part of the immune system. Like people with HIV, cancer patients on chemotherapy often suffer severe diarrhea. Charles Smigelski, RD, a nutritionist and researcher at Harvard University, reports seeing a cancer chemo patient who had disabling diarrhea for six months. Within a week on glutamine, his bowel movements were normal.

Smigelski is high on glutamine and other anti-oxidant supplements for people with HIV. He has about 100 HIV patients in his practice that are supplementing with glutamine and says, Most people report that they feel better on every level. It improves their energy, it reduces diarrhea, and it's hugely useful in wasting and dealing with oxidative stress. A ton of people swear by it.

Smigelski believes that such supplementation may be able to prevent or reduce lipodystrophy ( Crix belly ), thought to be a side effect of protease inhibitors. His patients find it useful for diarrhea caused by protease inhibitors as well. A very common experience is that someone will have protease related diarrhea. Immodium will stop the explosive diarrhea that often comes before people can get to the bathroom, but it won't firm the stools or reduce frequency. Glutamine, which I use in combination with probiotics (natural gut bacteria like acidophilus, lactobacillus, etc.), firms the stools. It really improves quality of life.

Body builders also tout glutamine because it is anabolic (builds muscles). A poster presented by Dr. Shabert at this year's International Conference on AIDS in Geneva reports that patients with wasting given 40 grams a day of glutamine (along with NAC, vitamins C and E, selenium and beta-carotene) gained an average of 1.7 kilograms (3.75 lbs) in lean body mass in 12 weeks. Patients in the control group were given glycine (another amino acid protein) and a multivitamin and they did not gain similarly.

Shabert notes that patients in a recent study using human growth hormone (which can have many unwanted side effects) put on a similar amount of weight in the same time period. But when they were followed up after stopping treatment, they lost the weight. Glutamine supplementation cost $250 while human growth hormone cost about $9,500. According to Shabert, growth hormone may force the body to make muscle at the expense of other vital organs. She says that the death rate of people using growth hormone was slightly (not significantly) higher than for the controls.

In support of Smigelski's views on glutamine and lipodystrophy, none of Shabert's subjects on glutamine developed the problem even though almost all were on protease inhibitors. However, it was a small study with only 21 subjects and its end point was never intended to find lipodystrophy.

Dr. Mary Romeyn, a physician with a large HIV practice in San Francisco and author of the 1998 book, Nutrition and HIV , says that low glutamine levels may be responsible for bad reactions to Bactrim so, those who need Bactrim might want to consider supplementation with glutamine.

Toxicity
Few physicians or nutritionists report any toxicities or side effects from glutamine even at high doses. Says Smigelski, It may heighten the effects of caffeine which, for many, might be a plus. People with liver disease need to count their glutamine dose as part of their protein allotment, and some believe that it can help liver health. However, people with end stage liver or renal disease may have trouble. According to Dr. Charles Noyer, who published a study of glutamine for intestinal problems in PWAs, people might have changes in mental status , including lethargy and sometimes even mania. In his study, no one suffered these effects, however. Dr. Shabert reports that a study of glutamine in people awaiting liver transplant found that it caused encephalopathy (brain dysfunction), but she hasn't had any problems using it so far.

Dosages
Smigelski recommends the following dosages, to be adjusted according to individual needs and responses. For diarrhea caused by protease inhibitors, 10 grams a day. To treat symptoms of infectious diarrhea, use 30 grams a day for one week. As a treatment for the symptoms of diarrhea caused by MAC or cryptosporidiosis, use 40 grams a day for a week. Maintenance dosages should be adjusted according to individual needs. Shabert's study found 40 grams a day helped people with wasting add lean body mass. All experts agree that Glutamine works best in combination with other anti-oxidants. Smigelski believes that it's never too early to start supplementation. For people with HIV he recommends 5-10 grams a day of glutamine, 1-2 grams NAC, along with Vitamins C, E and selenium (we might add beta-carotene, garlic and thioctic acid).

Most nutritionists prefer the powdered form of glutamine. It should be dissolved in water or juice and consumed quickly before it breaks down. Capsules are available, but it's believed that the powder is better absorbed and the number of capsules needed to reach your dose might actually promote diarrhea or gas because of the gelatin coating. Glutamine should be taken immediately before or after meals. Doses should be spread out to three or more times a day.

What People on Glutamine are Saying?
John, a client of the PWA Health Group, believes he's been HIV-infected since 1978 he had persistent generalized lymphadenopathy (lymph node enlargement) before AIDS was discovered. I've been through all the drugs, he says. I have multi-drug resistant HIV.

John takes the full range of anti-oxidant supplements including alpha lipoic acid, NAC, vitamin C and 8-10 grams a day of glutamine. He started on the regime because, I thought that one factor that was not being considered in HIV was the host. He laughs, I'm the hostess with the mostess, but he didn't want to provide a party atmosphere for his virus. John says that glutamine didn't help when he had diarrhea related to Viracept, but other than that, he hasn t had a problem with diarrhea. I know other people who take it, (glutamine) who believe they have seen an effect. As for his current health, "I'm OK. I can't see cause and effect, but I have no other real options." His T-Cell count is 370 and he does report serious fatigue, but no side effects related to glutamine.

Mark, also a client of the PWA Health Group, had an unwanted change in his numbers just after starting glutamine, but has no way of knowing whether it was related to the supplement. For a year, I watched my numbers fluctuate, he said. He started an anti-oxidant cocktail and, My numbers got worse. My lowest T-Cell count went down to 209. I stopped everything. I got it in my head that the glutamine was the problem because I thought it was the most important of the anti-oxidants.

Mark, a long term survivor , believes he became infected in the 70's, although unlike John, he has never met the definition for AIDS. Now, he says, I'm healthy as a horse. He was taking all the anti-oxidants but glutamine and recently added it back into his regimen. His numbers are still fluctuating.

Anti HIV Medications + Street Drugs: Some Cocktails Don't Mix

Beginning in October, the PWA Health Group started an intensive treatment education program for active and former drug users. Because there is so little hard information available on the specific hazards of mixing street drugs with anti-HIV therapies, we decided to ask Maia Szalavitz, illicit drug researcher par excellence, to get the scoop for us. Following is her special report:

For most drugs to be effective and not to kill you, they need to be metabolized [broken down] by the liver or kidneys. These organs have limited resources and a set number of chemicals which accomplish this task. Because of this, certain drugs, whether they're HIV medications or recreational drugs, can affect how other drugs act. This is called a 'drug interaction' and some of them can be deadly.

There hasn't been much research on how street drugs and HIV medications interact because there is little financial incentive for the pharmaceutical companies to do the work, and because the government believes "just say no," is the only way to deal with drugs. Certainly, your best bet is not to take street drugs at all if you are taking HIV medications. But some interactions are deadlier than others.

Ecstasy (X, MDMA): There has already been one death in England which resulted from a regular dose of ecstacy (MDMA, X) taken with Norvir (ritonavir). Norvir acts to slow down the liver enzyme that breaks down X so it makes the dose 5 to 10 times stronger. In addition, between 3-10% of the white population (the figure for other populations is not known) have a deficiency in this enzyme, which may be why some people overdose on what may be a safe dose for others. If you are taking any protease inhibitor [ritonavir (Norvir), nelfinavir (Viracept), indinavir (Crixivan), saquinavir (Fortovase)] or non-nucleoside reverse transcriptase inhibitor [nevirapine (Viramune), delavirdine (Rescriptor) or efavirenz (Sustiva)], X can be extremely dangerous. Of these, Norvir and Rescriptor seem to be the most dangerous, while Viramune and Sustiva may be less so although because effects in the test tube have sometimes been opposite to those seen in the body, this is hard to predict.

If you do take X with a protease inhibitor, wait as long as possible after taking the protease inhibitor to take the X, and be sure to have someone with you who knows what you've done in case you have difficulties. These overdoses are often not reversible, so it's really better not to mix these drugs!

Recent research has found that X damages serotonin neurons, so avoid it if you have a family or personal history of depression or anxiety disorders.

Alcohol: Videx (ddI) can increase the risk of pancreatitis (intense stomach pain that feels like it's going all the way through to your back. So, if you're using alcohol regularly, don t use Videx. There are other nucleosides to choose from.

Occasional and light use of alcohol is not known to interact with other HIV medications; however, chronic, heavy use can be destructive to the liver. This can be dangerous because the way that drugs are broken down can be hurt. More drugs will stay in your system for the most part, which is likely to cause overdoses and worse side effects. Alcohol can cause dehydration, so be sure to drink lots of water to help your body deal with any alcohol you drink.

Marijuana: Protease inhibitors may increase THC levels (the active ingredient in marijuana) so smaller doses may make you more stoned. This is also true of the synthetic version (Marinol) used in the treatment of weight loss. Since THC overdose is impossible, this interaction is not dangerous.

Sedatives: The sedatives Halcion (triazolam), Valium (diazepam), Ambien (zolpidem) and Versed (midazolam) can also be deadly if mixed with the protease inhibitors. Norvir has the largest negative effect. At high doses these drugs can stop you breathing. Ativan (lorazepam), Serax (oxazepam) and Restoril (temazepam) are safer with Norvir, and may actually be weakened by it.

Barbiturates: Crixivan may increase blood levels of phenobarbitol (Luminal), making overdose more likely. Other protease inhibitor interactions are also possible.

Cocaine (coke, blow): There are no known interactions between cocaine and HIV medications, but in the test tube, cocaine doubles the speed at which the virus reproduces, meaning it may speed up how sick you get.

Heroin (smack, brown, junk, China White): Norvir seems to reduce heroin levels by 50%, making overdose less likely. However, this drug and the other protease inhibitors have sometimes been known to have opposite effects (they cut methadone levels in real life, while test tube experiments predicted they would increase them), so caution is in order. Some synthetics sold as heroin (fentanyl, alpha-methyl-fentanyl) are potent in tiny doses and could be deadly if mixed with another drug.

GHB (gamma-hydroxy-butyrate, grievous bodily harm, liquid X is potentially dangerous with Norvir and other protease inhibitors.

Amyl nitrite (amyl nitrate/poppers): Glutathione is used by the liver to process amyl nitrite, and high glutathione is linked with survival. If using amyl nitrite cuts glutathione, it could lead to disease progression.

LSD (acid): No known interactions.

Ketamine (Special K): When combined with Norvir, Special K can lead to "chemical hepatitis," an unpleasant inflammation of the liver resulting in jaundice. A NY HIV doctor has seen two cases of it. Both went away in several weeks. But anything which damages the liver can be a serious problem for people living with HIV.

Amphetamines (dexedrine, amphetamine, methamphetamine, crystal meth): Norvir is predicted to increase amphetamine levels in the blood by a factor of 2-3. The other protease inhibitors should have less of an impact, but strange opposite results are always possible.

Ritalin: Norvir and other similar drugs can either strenthen Ritalin's effects or make it weaker. Beware!

Interactions not listed could be deadly. Street drugs are often not what they are sold as, they are frequently cut with substances that may interact with drugs themselves and their potency can vary wildly, even in the same batch. With the lack of research in this area, it's better to avoid potential interactions if at all possible.

Currently available from the PWA Health Group: *Albendazole | *Azithromycin | DHEA | HY2 | Hypericin/St. John's Wort | Isoprinosine | Itraconazole | Ketotifen | *Memantine | NAC | *NTZ | *Pentamidine | Peptide T | Ribavirin | *Roxithromycin | Saccharomycoses Boulardii | SSKT: Sho-Saiko-To | *Tinadazole | Thiotic Acid | *Thymosin-Alpha-1 *Requires Prescription

Pain Medications and Recovery    by Maia Szalavitz

People in recovery from addiction are often scared to take pain medication for fear that it will "reactivate" their urges to get high and lead to relapse. Some go so far as to refuse opiate pain killers after major surgery. Some members of 12 Step programs even advise others to forgo medication that their doctors have recommended.

This attitude can be severely destructive. Pain slows the healing process, and untreated pain is more likely to lead to relapse urges than properly treated pain. Even if your drug of choice was heroin or prescription opiates, you should not refuse appropriate, doctor-prescribed medication.

If you have severe, chronic pain and need to take opiates for a long period of time, you may become physically dependent on them and undergo withdrawal when these medications are stopped. People often confuse physical dependence with addiction, but they are not the same thing.

Addiction is compulsive use of a drug despite negative consequences. Dependence is simply needing a drug to avoid physical symptoms. If the consequences of dependence are improved health and decreased pain, it is not addiction. Most painkiller patients who become dependent do not become addicted. Don't let fear of dependence keep you suffering. Using doctor-prescribed medication as prescribed is not a relapse.

Here are some tips for people in recovery for dealing with severe pain:

1. Tell all your doctors about your history of addiction. That way, they'll be cautious in prescribing. If, however, non-opiate medications aren t effective, don t be afraid to speak up. If a doctor treats this as "drug-seeking," find another doctor. If you're in the hospital and feel that your pain medication is inadequate, ask to speak with the patient advocate or ombudsman.

2. Explore alternative methods of pain control. Some people find relief with acupuncture, massage, electrical nerve stimulation and other non-drug methods of pain treatment. They can't hurt, and they might help, so may as well try them. However, don't be afraid to admit it if you aren't getting what you need.

3. See a pain specialist. Physicians trained in pain control are much more likely to know the best way to deal with it than those who haven't worked in this area. Some of it is the opposite of what you'd expect, and there are several new drugs in the pipeline which may offer new ways of relieving pain and which non-specialists may not be aware of.

4. If you need to use opiates, try to maintain a steady level of pain relief. Research finds that people given opiates on demand are less likely to develop addiction than those who have to wait for medication to be given at a specific time. This is because if you wait in pain for medication, you start to develop a psychological association between the medication and the relief.

5. Also, the "up and down" feeling is reminiscent of what most addicts experience on the street. If you simply stay at a steady, well-medicated level, you won't have this sensation. Physicians call this type of prescribing PRN. One way of achieving it is with a patient-operated morphine (or other opiate) pump. It sounds strange, but keeping yourself comfortable is less likely to get you in trouble than waiting as long as possible and then taking the drug.

6. People on methadone may need higher doses of opiate pain killers than others do. Some people wrongly assume that if you are on methadone, you feel no pain and need no pain medication. This is not true, but because of tolerance, methadone patients may need extremely high doses (which could kill others) to get the relief they need. Again, don't be afraid to ask if you're not comfortable.

7. Pain medications can interact with HIV medications, particularly protease inhibitors [See our Information sheets on interactions between methadone and HIV medications for more details]. Be sure that all your doctors know about all the medications you're taking. Some HIV medications make painkillers stronger, others make them weaker. Don't take chances if you feel overmedicated or as though your breathing is slower than normal. Seek help, since these may be signs of an opiate overdose.

8. Tell your sponsor or other recovery support people about your use of pain medications. If you're afraid that you won t take them as prescribed, have a sponsor or friend keep the medication for you and give it to you as needed, keeping in mind that you should try for a steady state. Ask yourself: am I in physical pain or do I just want distraction? If you're honest with yourself, you'll know if you're drug-seeking.

9. If you attend support group meetings, talk about how you're feeling when you're there. Just talking about pain sometimes helps relieve it because fear and loneliness often make pain worse. Try to attend meetings if at all possible.

10. Alcoholics Anonymous has a very useful pamphlet, "The AA Member and Other Medications," which describes how members have dealt with the use of antidepressants and pain medication. If someone in the program tells you that, "You aren't sober, you have relapsed," because you have to take pain medication, ask to see their medical license and hand them a copy of the pamphlet for the program's official position on the issue.

    Copies of this fact sheet can be ordered from The PWA Health Group.

    HEPATITIS TREATMENT UPDATE - New Approvals, Not Much News. By James Learned

    Thymosin-Alpha-1 (brand name Zadaxin) has been approved in Mexico as a flu vaccine booster. Hopefully, Mexican approval for the treatment of Hepatitis B and Hepatitis C will follow shortly. Thymosin is an injectable synthetic version of a naturally occurring hormone that circulates in the body. It has been studied for a number of years for the treatment of HIV, as well as Hepatitis B and Hepatitis C. One of its appealing aspects is that it has almost no side effects. Thymosin shows promise as an alternative to alpha-interferon as a first-line treatment for chronic Hepatitis B. And combinations of thymosin/alpha-interferon as well as thymosin/alpha-interferon/ribavirin look promising for the treatment of Hepatitis C. A lot of folks are interested in thymosin, but it's been increasingly difficult to get a hold of.

    It's approved for the treatment of Hepatitis B, Hepatitis C and/or as a flu vaccine booster in Cambodia, China, Singapore, the Philippines, Peru, Myanmar, Argentina, Kuwait and Italy. Hopefully, now that it's been approved for use in Mexico, it may be more readily available to bring into the U.S. under the FDA's Personal Use Guidance. We'll keep you posted.

    SciClone Pharmaceuticals, the company that owns the rights to thymosin, has had more than its share of internal strife. But the company seems to be getting its act together, perhaps because SciClone is getting substantial financial assistance from its new partner, Schering-Plough. As Schering corners the market, future development of Hepatitis C treatments is worrisome.

    In mid-December, Schering-Plough received expanded FDA approval for its bundled product, Rebetron, as a first-line treatment for Hepatitis C. Rebetron is a package that includes Schering's brand of injectable alpha-interferon (Intron-A) and ribavirin capsules. Prior to December's expanded approval, treatment failure with alpha-interferon monotherapy was required before you could try the combination, which has a much better success rate (about 15% on monotherapy compared to 49% on the combination). Now you no longer have to wait. If you decide that you want to begin treatment for Hepatitis C, you can start with the combination and, if you're insured, they'll cover it. When Rebetron was initially approved in June, it was the first time in FDA history that two drugs had been packaged together in such a way that you couldn't get one (the ribavirin) without having to take the other (see Notes from the Underground, Issue 37).

    Many people would rather combine ribavirin with one of the other interferons on the market. By packaging ribavirin only with Intron-A, Schering-Plough and the FDA have drastically limited people's treatment options. Because of that and the astronomical price that Schering is charging for the bundled product, the PWA Health Group will continue to import ribavirin at a much lower price as we ve been doing since it was first looked at as an anti-viral for HIV in the late 1980 s.

    Another old friend, 3TC (Epivir), was approved in December for the treatment of chronic Hepatitis B. The brand name of the Hepatitis B version of the drug is (you might want to sit down) Epivir-HBV. The drug was approved primarily based on four one-year trials that involved almost 1,000 people. Three of the trials were placebo-controlled. The results of other international studies have been presented recently, showing marked reductions in liver cell damage and liver enzymes after two years of daily treatment. The approved dose is 100mg once a day, compared to 150mg twice a day for HIV. The problem with the data is that it doesn t tell us enough about whether or not the virus is cleared once these folks stop treatment.

    As in HIV, the Hepatitis B virus can develop resistance to Epivir if it's taken alone. Combination therapy for Hepatitis B may be a more useful way to go especially if you are co-infected with HIV.

    Note: If you have active Hepatitis B and start an HIV combination that includes Epivir, you're going to be really sick for a month or two while the infected liver cells die off. Check for Hepatitis B before starting an HIV combination with Epivir.

    Dr. Bernard Bihari has put out the results of an interesting observational study he conducted through his practice in New York. The study involved fifteen people with Hepatitis C, seven of whom are also HIV+. Each day, participants took between 2 and 7 capsules of HY2 (depending on each person's ability to tolerate the HY2) and 3mg of naltrexone (ReVia), an opiate blocker. HY2 is a form of St. John's Wort, a naturally occurring herb. Hypericin, a chemical derived from St. John's Wort, has shown strong anti-viral activity in the test tube against a wide variety of viruses. Each capsule of the HY2 used by Dr. Bihari's patients contains 750mg of St. John's Wort, with a 220% increase in hypericin content (2.25mg hypericin) over standard St. John's Wort preparations. This same HY2 is available at the PWA Health Group.

    Dr. Bihari has followed his patients for up to two years. In almost all cases, Dr. Bihari's patients latest lab reports show normal or close-to-normal AST and ALT results. These tests measure the levels of enzymes produced by the liver. The elevated enzymes which all of the participants had at the beginning of the study are usually an indication of liver inflammation or damage. Many study participants were using milk thistle and/or thioctic (lipoic) acid, popular supplements that enhance liver function. Four participants added ribavirin to their regimens.

    With these additional, varied therapies, and even the naltrexone, many questions remain. How much the HY2 contributed to people's successful drop in liver enzymes isn t entirely clear.

    One person who stopped taking HY2 and took regular St. John's Wort instead showed an increase in enzymes until he went back to the HY2. When two other study participants stopped their regimens for a while, their enzymes shot up, then decreased again after going back on the regimen. We know that taking ribavirin alone can sharply decrease liver enzymes; but when you stop ribavirin, enzymes pop back up. The same seems to be true of HY2 and the other treatments Dr. Bihari's patients are using. It may be helpful to give your liver a break for a period of time. But we don t know yet what will happen once these folks stop their regimen completely or whether anyone's virus will clear.

Index to Notes

copyright 1998 1999 by People With AIDS Working For Health, Inc.
REPRODUCTION IS HEARTILY ENCOURAGED.

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