Nelson Vergel from www.POWERUSA.org describes the latest advances in HIV and aging research. More information on www.NelsonVergel.com

1. Beyond Survival-
A Breakthrough in Well-Being
Nelson Vergel
Program for Wellness Restoration
Copyright © 2011 by Nelson Vergel

2. This information (and any accompanying printed
material) is not intended to replace the attention or
advice of a physician or other health care professional.
Anyone who wishes to embark on any dietary, drug,
exercise, or other lifestyle change intended to prevent
or treat a specific disease or condition should first
consult with and seek clearance from a qualified health
care professional.

3. These Slides Are Available at
PoWeRUSA.org

4. AGENDA
• Update on lipodystrophy
• How to prevent bone loss
• Protecting yourself from anal cancer
• Exercise: The best therapy
• What you did not know about testosterone
• Questions?

5. Glucose metabolism Dyslipidaemia Abnormalities of body composition
impairment
The changing pattern of clinical spectrum of
HIV: LIPODYSTROPHY and Non-infectious
Co-MORBIDITIES depict the HIV specific
Ageing phenotypes
Body image
HAND CVD Hepatic steatosis Bone & Kidney disease
alterations
Sexual
Depression HT Vit D T2D Cancer

6. Background
Interactions among aging, HIV, and HIV drugs increase the risk of
comorbidities. (Vance, Am J Nurs 2010)

7. Poly-pathology prevalence in cases and controls,
stratified by age categories
Pp 3.9% 9.0% 20.0% 46.9% Pp 0.5% 1.9% 6.6% 18.7%
Pp prevalence was higher in cases than controls in all age strata (all p-values <0.001)
Pp prevalence seen cases aged 41-50 was similar to that observed among controls
aged 51-60 controls (p=0.282)

8. Visceral Fat Reduction

9. Abdominal Obesity and the
Cardiometabolic Risk
OUTSIDE INSIDE
Intra-abdominal or
Visceral Fat
Waist Circumference Intra-abdominal Fat
Intra-abdominal fat is a
strong correlate of
Cardiometabolic Risk
9

10. High visceral fat (VAT) increases
cardiovascular risk
Triglycerides HDL-cholesterol
310 60
248
(mg/dl)
(mg/dl)
186
45
124
62
30
0
Nonobese Obese Nonobese Obese
Low High Low High
VAT VAT VAT VAT
10
Pouliot et al. Diabetes. 1992;41:826-834.

11. DAD Study:
Lipodystrophy Incidence 2000-2002 vs 2003-2006
2000-2002
2003-2006

13. Truvada vs Epzicom
Sustiva vs
Reyataz+Novir
A5224s

14. A5224s

15. Researched Options to Decrease Visceral Fat
Changing
Testosterone
HIV Meds?
Anabolic
Metformin?
Steroids?
Supplements
Egrifta ?
Low Carb,
High Fiber Weight Loss
Diet?
Exercise
Visceral Liposuction?
Fat

16. Reduction in Abdominal Subcutaneous and Visceral
Fat In Response to a 7% Exercise-Induced Weight
loss, 6 cm reduction in Waist Circumference
Visceral Fat
Subcutaneous Fat *p< 0.05 vs control
MEN WOMEN
* *
Reduction (%)
30 30
Reduction (%)
20 * 20 *
10 10
0 0
Control Exercise Control Exercise
16
Adapted from Ross et al. Ann Intern Med. 2001; Obesity Research. 2004.

17. DIET Study (Dietary Intervention:Effects
on Tryglicerides in HIV Lipodystrophy)
Using food records that began from 6 to 24 months before
development of fat deposition the following factors were
identified.
When compared to people with HIV who developed fat
deposition, patients without fat deposition had:
- greater overall energy intakes from their diet (p = 0.03)
- greater intakes of total protein (p = 0.01)
- more total dietary fiber (p = 0.01)
- more soluble dietary fiber (p = 0.01)
- insoluble dietary fiber (p = 0.03)
- pectin (P = 0.02)
Those without fat deposition also were currently doing more
resistance training exercise and were less likely to be smoking -
(only borderline statistical significance (p = 0.05))
Hendricks at al, Am J Clin Nutr, 2003 Oct;78(4):790-5

18. Newly FDA Approved Product
to Decrease Visceral Fat in HIV+ Patients
•2 mg injections under the skin every day. Effect
disappears when stopped
•A patient assistance program for those without
insurance and incomes under $60K
•More information on Egrifta.com

19. Effect of HIV Drugs on Lipids
Higher Risk Lower Risk
Stavudine- D4T Nevirapine- Viramune
AZT Tenofovir- Viread
Didanosine-DDI Abacavir- Ziagen
Lopinavir/r-Kaletra Cholesterol/ Lamivudine- 3TC
Amprenavir-Lexiva Emtricitabine- Emtriva
Triglycerides Enfurvitide-Fuzeon
Duranavir-Prezista
Sustiva (Atripla) Saquinavir- Invirase
Atazanavir- Reyataz
Raltegravir- Isentress
Maraviroc- Selzentry
Etravirine-Intelence
DHS/P
P

20. Lipoatrophy Deficits Requiring Correction
Temple
Fill
Cheek
Augmentation

21. HIV Medications and Lipoatropy
(Fat Wasting)
Low Risk
Higher Risk
Nevirapine- Viramune
Stavudine-D4T
Atripla & Complera
AZT
Tenofovir-
Didanosine-DDI? Lipoatrophy Viread/Truvada
Abacavir- Ziagen
Fat Wasting
Lamivudine- 3TC
Emtricitabine- Emtriva
Fuzeon
Isentress
Selzentry
All protease inhibitors

22. Carruthers Lipoatrophy Severity Scale
Stage 1 Stage 2
Stage 3 Stage 4
James J et al. Dermatol Surg. 2002;28:979-
986.

23. FDA Approved Facial Lipoatrophy Products
Off Label Use: Silicone Microdroplet, Artefill

24. Commonly Used Options for HIV-related Facial Lipoatrophy
(From FacialWasting.org)
Product Type/Sessions Approved? Cost
Sculptra Non- permanent Patient Assistance for Product only
http://www.needymeds.org/drug_list.taf
(New Fill- 3-7 sessions FDA approved ?_function=name&name=Sculptra
Labor cost avg. $500 per session.
PolyLactic Acid) needed, the 1 Full price: $1,100 per session for
touch up a year product.
Radiesse Non- permanent Limited Patient Assistance
(Calcium Available
hydroxylapitite 2-3+ sessions FDA approved http://www.radiesse-fl.com/Physician-
(CaHA) section/Patient-access-program/
needed, then 1 Full Price: $1,200 per session.
microspheres) touch up a year
Off label use-
Permanent FDA approved for
Silikon 1000 intraocular No Patient Assistance-
Microdroplets 4-8+ sessions injections to treat $700-900 per session
needed CMV- related
retinal detachment
Available in
PMMA Permanent Mexico, Brazil and $3,000+ avg. total cost for total
other countries.
(Polymethyl- 1-2 sessions FDA approved:
reconstruction in Mexico:
methacrylate ) Artefill but too http://www.avantiderma.com/
needed expensive
Number of sessions depends on severity of facial lipoatrophy

25. Proposed Decision Memo for Dermal injections
for the treatment of facial lipodystrophy
syndrome (FLS) (Jan 2010)
“Dermal injections for facial lipodystrophy
syndrome are only reasonable and necessary
using dermal fillers approved by FDA for this
purpose, and then only in HIV infected
beneficiaries who manifest depression
secondary to the physical stigmata of HIV
treatment. All other indications are
noncovered.”

26. Pre- and Post-Silikon 1000
14 treatments over 2 years, 24 cc total

28. Protecting Your Bones

31. D
E
X
A
B
O
N
E
S
C
A
N

32. Bone Disorders in HIV
Treatments for bone loss
– Resistance exercise, preventing wasting
syndrome, and avoiding tobacco
– Calcium (1000- 1500 mg/day) and Vitamin D
(400-1000 IU/day ). Get 20 minutes of sun
daily
– Biophosphonates (Alendronate- Fosamax)
– Calcitonin (Intranasal and oral)
– Teriparatide (Forteo)
– Testosterone and/or thyroid replacement
therapy

33. Bone Drugs Once monthy
IV
Once a year
Subcutaneous, once daily

35. NNRTIs? Tenofovir?

36. Vitamin D Terminology
Serum 25-hydroxy vitamin D = 25-OHD
Indicator of vitamin D nutritional “status”
Vitamin D Status 25-OHD serum concentration
ng/mL nmol/L
Deficient <12 <30
Insufficient 12 to <20 30 to 50
Sufficient >20 to 50 >50 to 125
Excess >50 >125
http://books.nap.edu/openbook.php?record_id=13050&page=11

38. Vitamin D Therapy Decreases
Parathyroid Hormone (PTH) in Patients
Taking Viread (tenofovir)
• Randomized trial of Vit D 50,000 IU/wk x 12 weeks vs. placebo in patients on (n=118) or not on
(n=85) TDF
• Higher baseline PTH levels at baseline in TDF group
• Vitamin D had no impact on PTH levels in patients not on TDF
Mean Baseline PTH by Vitamin D status and Tenofovir Use
PTH Differs by Tenofovir use, not Vitamin D status
Changes in PTH on study
52 TDF No TDF
43
35 Day Day
Change Change
0 0
27
Vit D 47 -6 26 -2
P=0.001 P<0.001
PBO 37 +2 25 0
Havens P, et al. 18th CROI; Boston, MA; February 27-March 2, 2011. Abst. 80.

39. Human Papiloma Virus (HPV) Related
Cancers
HPV Infection
Incidence of HPV infection
increases with sexual exposure
Re-infection
Associated with
persistent risk factors
Clearance
Common; increases after the age of 40
(as the immune system clears the virus)
Reactivation
Mainly associated
with
immunosuppression
Persistent Infection
Associated with the development of cancer
Cancers caused by HPV: Cervical, Vagino/vulvar, Penile, Anal, Oropharyngeal, Squamous cell
Higher risk with sero-types: 16, 18, 45 and 56
Levine A, et al. 49th ICAAC; San Francisco, CA; Sept. 12-15, 2009; Abst. 400.

40. Methods to Detect Anal
Warts, Cancer, and Dysplasia

41. Anal Cancer in HIV+ Men and Women
Diagnosis and Treatment
 Pap-smears and simple anoscopy done in the office.
Cytology obtained from pap smears.
 Outpatient under anesthesia: after high resolution
anoscopy (HRA) with vinegar, any lesions are treated with
infrared coagulation (IRC), which involves inserting a light
probe into the anal canal under direct visualization,
touching the tip of this light probe to the lesion, and
delivering a pre-specified amount of energy.
 Trained Physicians by UCSF’s anal neoplasia and research
group web site :
http://www.analcancerinfo.ucsf.edu/

43. Signs and Symptoms of Low
Testosterone
 Loss of muscle mass and strength
 Loss of libido and erectile dysfunction
 Depression
 Lethargy (fatigue, lack of focus)
 Bone loss
 Some regression of secondary sexual
characteristics (body hair loss, etc)
 Low or no sperm count
Tenover JL. Endocrinol Metab Clin North Am. 1998;27:969-987
Petak SM, et al. AACE Clinical Practice Guidelines. Available at: http://www.aace.com/clin/guides/hypogonadism.html

45. Testosterone and Aging

46. Testosterone Fractions in the Blood
Free T
2%
Albumin-bound T
38%
T = testosterone
Only 2% is free
Sex Hormone Binding Globulin
testosterone SHBG-bound T
and 98% is bound 60%

47. (binds testosterone)

48. Testosterone Deficiency
(Hypogonadism)
• Normal levels in blood:
Men... Total test. 300-1100 ng/dL,
Free test. 5 - 21 ng/dL
Women... Total test. 10-50 ng/dL
Free test. 0.10-0.85 ng/dL
• Symptoms of testosterone deficiency:
Fatigue, low or lack of sex drive, poor appetite,
loss of muscle mass & strength, depression

49. The HPT Hormonal Axis
H
P
T

53. Testosterone
Replacement Benefits Mental
focus
Stamina and Bone Strength
Sexual function
Lean
Body
Mass

54. Testosterone Metabolites and Their Functions
LH Dehydro Testosterone
(DHT) (by 5α-reductase) Androgen
Receptor
Skin, Prostate
Testostero Direct Effect
ne Androgen
5-7 Muscle, Brain Receptor
mg/day
Estradiol (by aromatase)
Hair, Brain, Bone Estrogen
Oxidation by Liver
Receptor
Elimination by Kidneys

56. Testosterone Options Gels
Buccal
Injections
Gels
Pellets
Patch

57. Potentially Approved in the Next 12-24 Months

58. Side Effect: Gynecomastia (breast enlargement in men)
Treatment: Estrogen Blocker Medications or surgery (in worst cases)

59. Side Effect: Increased number of red blood cells (polycythemia)
Watch out for
hematocrit over 52 !
Solution: Donate blood
or therapeutic phlebotomy
(4-5 units every 3-4 months)

60. Side Effect: Testicular Shrinkage (atrophy)
Treatment:
Human Chorionic Gonadotropin
(hCG)

61. Side Effect : Increased prostate size
(benign prostatic hypertrophy)
Prevention:
Digital Rectal Exam (DRE)
Prostatic Specific Antigen (PSA)
blood test

62. For More Information:
TestosteroneWisdom.com

63. Exercise, the Best Therapy for Most Health Problems

64. Low Arm Muscle is associated with
highest population-level mortality risk
in multivariable analysis
20%
Population Attributable Risk
15.1%
15%
10%
7.2%
6.5%
5%
0%
Arm SM Leg SM VAT Tertile 3
Tertile 1 Tertile 1
Tertile of Skeletal Muscle or Adipose Tissue

65. Exercise: The Best Medicine
Benefits:
total and abdominal fat
improves insulin sensitivity
improves glucose tolerance
increases HDL cholesterol
triglycerides and LDL
increases muscle mass
improves endurance
improves strength
improves bone density
improves mood
decreases frailty

66. EXERCISE FOR BEST RESULTS

67. Aerobic (Cardiovascular)
Exercise
 Start with a brisk walk every day if tired
 Concentrate in low impact or no impact
exercises (e.g. Elliptical Trainers)
 Do what you enjoy (bicycling, roller
skating, etc)
 Good for burning fat, triglycerides, blood
sugar, but it may decrease muscle mass
 20 - 30 minutes 3-4 times a week is
enough for many people
 Cardiovascular exercise may increase fat
loss under the skin

68. Progressive Resistance
Exercise (PRE)
 Warm up and stretch before a session
 Start with compounded exercises
 Lift maximum weight for muscular failure
(exhaustion) at 8-12 repetitions
 One body part per week
 One hour sessions 3-4 times a week
 One light set and two heavier sets per body part
 If no access to a gym, start with crunches, push
ups, and squats at home. Use stairs!
 For more details, visit www.medibolics.com

69. Best Exercise Sites with
videos, etc
www.exrx.net
www.MyFit.ca
Ipod exercise routine downloads:
http://www.menshealth.com/download/

70. For More Information
 More details in “Built To Survive” and ”Testosterone- A
Man’s Guide” (amazon.com or testosteronewisdom.com)
 Email:
Nelson Vergel – Nelsonvergel@yahoo.com
 Websites:
www.powerusa.com
www.facialwasting.org
www.tpan.com
www.TheBody.com
 Join my Internet discussion group by sending a blank email
to Pozhealth-subscribe@yahoogroups.com

71. Questions?