This article by Sean Hosein first appeared on the CATIE website here  

Une version française est disponible ici. 

In high-income countries such as Canada, Australia and the U.S. and in regions such as Western Europe, huge advances have been made in the treatment of HIV disease. Researchers increasingly expect that a young person who is diagnosed today and who initiates potent combination anti-HIV therapy (commonly called ART or HAART) and who has minimal co-existing health conditions should have several additional decades of life expectancy.

The combinations of therapies available for the initial treatment of HIV are plentiful. Furthermore, pill taking has been simplified by the availability of the co-formulation of several drugs into one pill, creating an entire regimen in a single tablet. Such single-tablet regimens need only be taken once daily. However, things were not always this way.

A look at the past

Initial treatment for HIV infection, when it became available in the late 1980s, consisted of a single drug—the nuke (nucleoside reverse transcriptase inhibitor) AZT (zidovudine, Retrovir)—given at high doses and taken every four hours. Such a regimen frequently caused headache, nausea, vomiting and damaged the bone marrow.

In the early 1990s, other anti-HIV drugs in the same class became available, including the following nukes:

• ddC (zalcitabine, Hivid)
• ddI (didanosine, Videx)
• d4T (stavudine, Zerit) 

These three drugs, commonly called d-drugs, initially appeared to be better tolerated but soon showed their own side effects, such as peripheral neuropathy (painful nerves in the hands, feet and legs). ddC is no longer manufactured and treatment guidelines in high-income countries now discourage the use of d4T and ddI.

In 1996, a new class of anti-HIV drugs became available—protease inhibitors (PIs). When used in combination with nukes, the results were dramatic. For the first time in the history of the AIDS pandemic, people showed sustained recovery from AIDS-related infections.

However, shortly after HAART became available, reports emerged of a strange syndrome of changes in body shape sometimes associated with the loss of the fatty layer just under the skin. This loss of fat, called lipoatrophy, affected all parts of the body but its effect on the face could become most distressing.

Initially, because PIs were the latest class of anti-HIV therapy, they were suspected as the culprits. However, a few years later, researchers began to realize that exposure to d4T and, to a lesser extent, AZT, was linked to lipoatrophy. Today, drugs such as d4T and AZT are generally not recommended as first-line therapy in high-income countries.

Nukes today

In the current era, nukes remain the backbone of many regimens. Nukes commonly used today include the following combinations:

• abacavir + 3TC – sold as a fixed-dose formulation called Kivexa (or Epzicom) and also found in Trizivir
• tenofovir + FTC – sold as a fixed-dose formulation called Truvada and also found in other combinations such as Atripla, Complera and Stribild 

A lingering sense of caution

Decisions about starting therapy for HIV infection have always been challenging; both doctors and their patients have weighed the risks and benefits, as well as a person’s ability to take HIV medicines exactly as directed for many years. In the current era, with safer, simpler therapies and more results from clinical trials, the risk–benefit ratio has swung strongly in favour of very early initiation of therapy. The most recent version of the U.S. Department of Health and Human Services’ (DHHS) HIV/AIDS Treatment Guidelines recommends early therapy for all HIV-positive people, for two reasons, as follows:

• At the level of the individual, early treatment can help preserve the immune system and improve health.
• From a public health point of view, treating more HIV-positive people reduces the amount of HIV in their blood, other tissues, and genital fluids. The result is decreased sexual infectiousness. As a result of this reduced infectiousness, at the level of a large urban area or region, widespread use of ART can help to reduce new cases of HIV transmission. This approach of treating people to reduce their infectiousness is called TasP—treatment as prevention. 

Despite the general tolerability and safety of Kivexa and Truvada, some HIV-positive people and their doctors remain somewhat wary of nukes in general, given their checkered history, and wonder about the potential of these drugs for causing new, unknown side effects. This latter concern is increased as HIV-positive people age and need to take multiple medications, heightening the potential for drug interactions and side effects.

Emerging research suggests the possibility that nukes can affect the energy-producing parts of cells (mitochondria). However, nuke combinations commonly used in the initiation of therapy today have not been proven to cause mitochondrial damage that is directly linked to the ill health of ART users.

Aging and HIV

Some researchers have found hints of apparently accelerated aging in some HIV-positive people. Specifically, some organ-systems, such as the brain, heart, blood vessels and bones, appear to have aged more quickly than they should.

The cause of this apparent aging is not clear.

If premature or accelerated aging does exist in HIV infection, there may be several potential causes affecting different people, including the following:

• long-term exposure to specific proteins produced by HIV-infected cells
• higher-than-normal levels of inflammation, which accompanies chronic viral infections such as HIV
• substance use
• tobacco smoking
• co-infection with other germs, such as members of the herpes virus family—CMV (cytomegalovirus) and EBV (Epstein-Barr virus) 

The immune system and aging

Several research teams have found that, if left untreated, HIV infection does prematurely age the immune system. HIV appears to cause this by repeatedly activating the immune system and producing inflammation. This virus also appears to cause complex and poorly understood changes to the immune system shortly after it enters the body.

ART greatly reduces HIV-related inflammation but cannot entirely eliminate it. Prolonged exposure to higher-than-normal levels of inflammation is associated with many chronic illnesses and it is possible that such inflammation over the long-term may play a role in reports of accelerated aging seen in some HIV-positive people in studies. However, it is important to bear in mind that exposure to unhealthy behaviours—particularly tobacco smoking—also causes inflammation. Separating all the possible drivers of accelerated aging in HIV-positive people will not be easy and will require many studies, some of them quite expensive and daunting in their complexity.

Much caution needed

A research team in Australia has been exploring the theory that nukes somehow contribute to the apparent acceleration in aging in HIV-positive people. Their work, conducted in complex laboratory experiments on cells from HIV-negative and HIV-positive people suggests the possibility that the drug tenofovir (Viread) may accelerate the aging of the immune system. However, we urge our readers to treat this finding with a great deal of caution, if only because the results from the Australian experiments are not definitive. Furthermore, due to built-in limitations of their study’s design (it is cross-sectional in nature), questions remain about the significance of their findings. Next up, we will explore some of the issues related to the Australian study.

—Sean R. Hosein

REFERENCES:

 1. Boasso A, Royle CM, Doumazos S, et al. Overactivation of plasmacytoid dendritic cells inhibits antiviral T-cell responses: a model for HIV immunopathogenesis. Blood. 2011 Nov 10;118(19):5152-62.

 2. Herbeuval JP, Nilsson J, Boasso A, et al. HAART reduces death ligand but not death receptors in lymphoid tissue of HIV-infected patients and simian immunodeficiency virus-infected macaques. AIDS. 2009 Jan 2;23(1):35-40.

 3. Bestilny LJ, Gill MJ, Mody CH, et al. Accelerated replicative senescence of the peripheral immune system induced by HIV infection. AIDS. 2000 May 5;14(7):771-80.

 4. Leeansyah E, Cameron PU, Solomon A, et al. Inhibition of telomerase activity by HIV Nucleos(t)ide Reverse Transcriptase Inhibitors: a potential factor contributing to HIV-associated accelerated ageing. Journal of Infectious Diseases. 2013; in press.

 5. Payne BA, Wilson IJ, Hateley CA, et al. Mitochondrial aging is accelerated by anti-retroviral therapy through the clonal expansion of mtDNA mutations. Nature Genetics. 2011 Jun 26;43(8):806-10.

 6. Helleberg M, Afzal S, Kronborg G, et al. Mortality Attributable to Smoking Among HIV-1-Infected Individuals: A Nationwide, Population-Based Cohort Study. Clinical Infectious Diseases. 2013; in press.

 7. Rasmussen LD, Kessel L, Molander LD, et al. Risk of cataract surgery in HIV-infected individuals: a Danish nationwide population-based cohort study. Clinical Infectious Diseases. 2011 Dec;53(11):1156-63.

 8. Guaraldi G, Orlando G, Zona S, et al. Premature age-related comorbidities among HIV-infected persons compared with the general population. Clinical Infectious Diseases. 2011 Dec;53(11):1120-6.

 9. Pathai S, Lawn SD, Weiss HA, et al. Increased ocular lens density in HIV-infected individuals with low nadir CD4 counts in South Africa: evidence of accelerated aging. Journal of Acquired Immune Deficiency Syndromes. 2013; in press.

 10. Smith RL, de Boer R, Brul S, et al. Premature and accelerated aging: HIV or HAART? Frontiers in Genetics. 2012;3:328.

 11. Carr A, Samaras K, Burton S, et al. A syndrome of peripheral lipodystrophy, hyperlipidaemia and insulin resistance in patients receiving HIV protease inhibitors. AIDS. 1998 May 7;12(7):F51-8.

 12. van der Valk M, Gisolf EH, et al. Increased risk of lipodystrophy when nucleoside analogue reverse transcriptase inhibitors are included with protease inhibitors in the treatment of HIV-1 infection. AIDS. 2001 May 4;15(7):847-55.

 13. Cohen S, Janicki-Deverts D, Turner RB, et al. Association between telomere length and experimentally induced upper respiratory viral infection in healthy adults. JAMA. 2013 Feb 20;309(7):699-705.

Memories, may be beautiful and yet

What's too painful to remember,

We simply choose to forget.

Barbra Streisand: The Way We Were 

As you get older things come back to you out of the blue. They do. Unannounced, unexpected and unwanted most of the time and usually in the quiet, more contemplative moments when you just want to switch off and not think of anything.

When you’re young, you’re busy building up libraries of experiences and memories and filling your head and heart up with trivia and absorbed knowledge. When you’re older, your memory banks are stuffed to the gills and although you may not be able to remember what you did yesterday, your childhood and later years will burst out of dusty memory files, in spontaneous clips of recollection and without apparent rhyme or reason.

So it is with me and especially concerning HIV. Not only HIV actually but almost every mistake I ever made as a child, teenager or young adult reappears to jab insistently at my conscience again.

Some of them are still too embarrassing. I just have to shrug them off with a shudder and a, ‘can’t cope with that now’ sort of thing. However others are things I never imagined would resurface and although uncomfortable, probably need to be faced.

The HIV memories though, are a special category to themselves and they’ve been interrupting my present life with unnerving regularity lately. It’s probably to do with accepting your mortality and all that sort of amateur psychoanalysis and I admit, that is a tricky concept for me but I also believe that there’s nothing wrong with revisiting horrors and traumas. I’m not looking for any sort of closure; people with HIV don’t get closure until their last breath but I find it therapeutic looking back and knowing that I can deal with it now when I couldn’t at the time.

Here in the Netherlands, the death surge due to the virus came a short while after that in the US. We looked across the Atlantic in slight disbelief, at the stories that were emerging out of New York, and San Francisco. It just didn’t seem a global threat at the time because it wasn’t happening here on the same scale. Of course people were beginning to die, especially people working in the airlines and other international companies at the same time but unless it touched us personally, we carried on pretty much as normal. Then my partner and I slowly but surely learned of friends and acquaintances being infected and the hospital, house visits and funerals began.

The first memory that came back to me recently was of a friend who was what you would call a ‘snappy dresser’, someone who took pride in his appearance and enjoyed life to the full. When his face and body became covered with KS lesions and his mouth was constantly surrounded by saliva, I remember thinking that it had little directly to do with me and still felt somehow detached. I wasn’t cold-hearted or unemotional; at that time, I just felt that this sort of thing could never invade my own life.  What I do remember, is how sad it made me feel that someone so vital and so fastidious about his appearance could be so quickly reduced to those purple blotches and little else.

When he died, my partner and I were given some unimportant, small things but above all, his clothes and I still break out in a cold sweat remembering how odd that felt and how ‘wrong’ somehow. I also can’t remember his funeral and that troubles me. Maybe that will come back one day too.

What these memories do allow me to do, is come to terms with my dispassion at the time. I was naïve and I realize that now and maybe it’s a human reaction to separate yourself from reality in order to protect yourself. Soldiers at war must do it all the time.

Another awkward recollection that surfaced recently was that of a colleague and friend who calmly told me one day in the staff room at school that he was positive. I was shocked but not surprised. Of course I knew he was gay and knew a little of his personal life and although his behavior was no more risky than the rest of us, we were all slowly becoming more aware of the dangers and the consequences. He carried on teaching for quite a while and to his eternal credit, told the head of the school and school governors straight away. This memory is a positive one in that I was and still am, full of admiration of the way they handled it. These were early days and yet the school supported him through thick and thin and although he was teaching young children who had daily accidents with bleeding and bruising, they trusted him to always do the right thing and he did. I somehow doubt that school authorities would be so understanding these days and that’s really sad.

I was one of the last people to speak to him as he lay dying at home and it was his compassion to me as I struggled to hold back the tears that sticks in my memory. He took my hand, said it would be okay and that he was okay with it and then said goodbye; with meaning. An hour later he was gone. Yet in the memory that recently came back, I remember most clearly the white pimples on his face which I know now were probably caused by the medication. Strange what sort of things stick in the memory!  I had to speak at his funeral in front of his friends and family, other teachers and one or two parents and it was unbearable. Needless to say, I didn’t do a great job of it and only just struggled through to the end. That still feels so bad because I’m sure he would have been far more composed had it been the other way round.

His partner was the next to go in our circle. We didn’t know him that well but had got to know him during the last months of Steve’s life. He was a young guy, cynical and street-wise and we visited him in his last weeks too. That particular memory hit me in the middle of the night sometime last week and took me back to his small, third story apartment with white walls and dozens of religious icons, paintings and statuettes filling the place with a church-like atmosphere. It was almost surreal seeing him so ill in that context but I can still see those religious symbols and still recall how ironic I found it at the time. 

I recently saw a documentary about how AIDS struck the Dutch national airline KLM pretty severely in those years. The airline kept much of it hidden from the public which may seem slightly underhand now but behind the scenes, they cared for the victims and their families and went out of their way to ‘share’ the problem. The public silence was probably understandable at the time but the in-house after-care was impressive.

We had made friends with two KLM employees a year or so before and got on with them really well but they too eventually succumbed to AIDS. Those memories are luckily of good times and laughter and not so much of the details of their deaths. By that time, nobody was surprised anymore when they heard that someone in their circle ‘had it’. You and they got on with it and you did what you could when necessary. The virus had made us all into cynics with walls but also people who learned to deal with it when it happened.

That built-up experience probably saved my sanity when my partner also became ill. No details necessary here but among the memories that flood back more often than ever these days is that of driving to the hospital every day with his mother, just hoping above hope that the doctors had found something new to try. He had a PCP type lung infection and lay there, a skeletal shell of the man he used to be and there seemed to be only one inevitable outcome. He’s since told me that looking in the mirror and seeing himself as he was, shocked him into triggering a subconscious fight back which probably saved his life; plus the fact that the fantastic doctors found an antibiotic combination at the last minute which allowed him to slowly claw his way back to health. Much of that time is still a blur. More specific memories will probably emerge the older I get.

I frequently think of the effect that had on his family and friends. His sister came up from France with her boyfriend, who stood the whole time at the foot of the bed like the angel of death and didn’t say a word. There was something both weird and spiritual about that at the time but really, I don’t think he knew what else to do.

My partner’s best friend since his school years also eventually visited after putting off and prevaricating because she couldn’t cope with it. She wasn’t much use, bursting into tears and staying about ten minutes. I understood that perhaps better than he did but he never forgave her and they never spoke again. Other disappointments with other friends and acquaintances at that time aren’t worth remembering but they were there.

My partner survived, recovered to his old self and despite two serious illnesses since, is still going strong and although we eventually split up, we still have a close relationship. What doesn’t kill you makes you stronger eh!

So that’s what’s increasingly happening to me in my old age. The past drifting in and out of my consciousness like so many ghosts. I can’t shut these recollections out because I can’t predict them but then again, I’m glad of them because they allow you to revisit situations in glorious memory technicolor and re-evaluate what they meant. I still can’t remember what I did two days ago, or who played what on the TV but memories from long ago seem to pop up via a smell, or a taste, or a tune, or just in the empty quiet times between living.

Perhaps as you get older you have more of those times and your memories get the chance to sneak in because your brain isn’t so hyperactive. At first, I took it as a negative sign that I was speedily heading into senility because I remember my grandmother doing the exact same thing but now I’m glad that these things come back because we never take photos at the time; or perhaps that’s exactly what our memories are.

I don’t know what possessed me but it was a Friday night and I’d been stuck inside for what seemed the whole winter. I had a severe case of cabin fever and had to get out. It was nine thirty in the evening; a time when I’m normally fixated on the box and longing for my bed because the feet are playing me up and I feel like crap. Then out of nowhere came this urge to go out and meet people - gay people.

There was another motive. I’d been contacted via the internet by an attractive man just a couple of years younger than myself. Cultured, interested in the arts, music, seen a bit of life and wanting to get to know someone at least superficially before hitting the sack; you know the type. He’d expressed interest in a meeting and said that he was in the bar on Friday nights and specifically, this Friday night.

Now despite my dotage, I’m not stupid and fully realise that that is not a date under anybody’s definition. He hadn’t arranged a time, so clearly wasn’t so interested that he wanted it contractually bound. It was a vague, ‘maybe I’ll see you there’ sort of thing. Nevertheless, it was the deciding factor and I decided to give my need for social contact and the possibility of something more a go; you should never give the needy half a chance!!

The last time I’d been to a bar in Amsterdam was probably two or three years ago. I can’t be more specific because my memory about that sort of thing’s shot to pieces these days. One of the reasons is that the bars are soulless deserts until about ten thirty at night and don’t get busy until after the witching hour. By that time normally, I’m in a medication-induced half-sleep and battling the demons in my feet and legs. This particular evening however, I was wide awake; in less discomfort than normal and seized by the need to take advantage of every window of opportunity my neuropathy gives me. Nevertheless, I knew that just getting to the nearest bar wasn’t going to be easy, requiring some walking and a tram ride and taking the walking stick wasn’t an option, so I took an extra pain killer just in case.

Now I’ve learned a thing or two over the years and in preparation, gave myself a serious talking to. I awarded myself ten self-confidence, bonus points to start off with, with the aim of hitting more before the evening was over and knowing that point zero was the time to come home. For those who don’t understand, these are the single guy’s imaginary boosts to his confidence designed to make him feel good enough about himself during the evening ahead and help him through the first hour or so, or at least until drunk enough not to care anymore. 

Then came the hour of primping and preening in the bathroom. Don’t laugh, the older you get, the longer it takes to achieve even looking your real age! So nose hairs, ear hairs, wayward eyebrows, goatee and side burns were all dealt with. Showering, scrubbing, hair washing and personal hygiene all scrupulously done. 

Clothing was the next problem. It’s still winter, so showing off the hairy chest under the T-shirt ‘V’ wasn’t an option and I needed a top jacket that would have enough pockets to stuff the cap, gloves and scarf in when I got there. I settled for good-fitting jeans and a shirt big enough to hide the spare tire. Both jeans and shirt were dark coloured. I wanted to blend in, not stand out like a geriatric peacock. So, finally satisfied that no matter what I did, I wasn’t going to improve the best I could be, I set off on my little adventure.

I was heading for a bar that I thought would be the most comfortable and least intimidating for a first venture out in a long time. From what I remembered, the patronage was a mix of bear types, bar flies, bored tourists and Asian boys with their mentors, plus the odd complete psycho to liven up the proceedings. More importantly, it was generally a slightly older crowd and I wasn’t going to expose my fragile ego to a bar full of narcissi (is that the plural of Narcissus?)

When I arrived outside the bar the feet were playing up, the butterflies were doing the fandango in my stomach and I nearly turned around and went back home. I had to lecture myself; ‘For God’s sake, you’re 63, not some virgin teenager hitting the scene for the first time!’ The virgin teenager in me was screaming to get the fuck back home but bravado won out and I walked in.

Now body language is everything during the first two minutes when you walk into a bar. I knew this and had rehearsed the casual confidence and natural half smile that were necessary but still stumbled in with two left feet; fixed my rabbit-in-the-headlights stare on the row of stools at the bar and flew, jet-fuelled onto the nearest vacant stool. One of my ten self-confidence bonus points already gone and the evening hadn’t even begun. Not a great start and the disinterested glances that greeted my arrival seemed to go on for hours. Nevertheless, once ensconced on my stool, I felt more at ease and ordered a beer from the grizzled barman. The last time I’d been here, this barman was on my wish list for Christmas but time takes its toll on us all,l I guess.

A beer wasn’t a good idea considering my medication but it was ordered before my rational brain kicked in. Oh well, one wouldn’t harm. Actually, after five minutes, most of my fears were ebbing away. One thing about gay bars in Amsterdam is that they never change, never! The bar owners are too tight to invest, the few tourists that still come find it quaint and the local clientele is not that demanding. The only thing that moves with the times is the price of drinks. Three and a half euros for a small beer; good grief!

My favourite begin to an evening had always been perching on my stool, with my back to the wall and with a good view of the circus. Taking time to case the joint and see what, who and where was essential, especially if I was on my own. See but not be seen was the motto, at least in the beginning. I began by looking around to see if internet guy was here and then realised I wasn’t entirely certain I’d recognise him if he was; there’s a certain generic look that I find attractive but lots of guys have that look and no matter how much I tried, I couldn’t really recall his profile face clearly. I had to hope that he would find me first. Actually, the bar that Friday was not exactly teeming with ‘my types’, so I was pretty sure I hadn’t missed him.

There were two guys whom I recognised from twenty years ago. The difference being that now they were both bursting out of their T-shirts like Arnold Schwarzenegger and were probably just as old. Always intimidated by muscle Mary’s, I bitchily concluded that these guys were steroid queens but nevertheless still slumped over my bulging stomach on the stool. One more point lost!

There was a clique of a few really young guys acting like humming birds round a feeder. They were hyperactive and alternating between frenzied chatter amongst themselves and flitting to the bar to flash impossibly long eyelashes at whoever might buy them a drink. 

Another group was gathered round the pinball machine. These were lads in their late twenties; smartly dressed, short hair and street savvy. These guys are at the peak of their game and know their own pulling power. I used to be like that for a few short seconds in time. However, that didn’t shake my confidence; I’ve never been into younger guys so I didn’t see them as intimidating, until that is…

…I’d been staring for too long. I realised it at the very second that one of them turned to meet my gaze but it was too late. The lip curled into a Presley sneer and the eyes narrowed, gimlet-like, into bullets of sheer venom. As he turned to inform his friends that the perv in the corner was eying him up, another self-confidence point bit the dust. The collective group glare that followed nearly lost me another point but by that time I was ordering another beer I shouldn’t drink and considering flight.

For the next few minutes, I counted all the spirits bottles hanging behind the bar; fixated on the mechanical porn on one of the TV screens and tried to regain some self-control. Luckily I was rescued by a tap on the shoulder. Thinking it was the guy from the internet, I turned optimistically to greet my saviour. It wasn’t that guy but it was someone else that I half-remembered from years ago and he looked pretty good! After confirming mutual recognition, I bought him a beer and he sat down next to me. My twenty five year old internal man-about-town, returned and the next half an hour was spent chatting, catching up on mutual friends and subtle but unmistakeable flirting. The restoration of a point to my confidence chart came from the fact that he was also flirting with me! And he wasn’t drunk and didn’t seem to have any hidden agenda; yippee!

Okay, to cut a long story short; I’d repressed my needy gene, brought about by a long time without this sort of contact and was playing it cool. I was proud of myself because everything was in control and we had clicked. You know that feeling when it’s just right and you know you’ve read the signs and body language correctly. It got to the point where I was musing on the evening’s end and what I’d do if internet guy walked in. Overconfidence; fatal!

He asked me if I’d like to get out of there and go back to his place nearby. I contained my excitement and feeling like that teenage virgin again, demurely accepted. Trust my rational mind to choose that moment to poke me in the conscience…’Ahem, aren’t we forgetting something!’ I swear to God, I got icy chills but came out with it anyway. Lowering my head close to his, I uttered the words!

“By the way; I think you should know; I’m HIV positive; is that going to be a problem?”

I honestly thought it wouldn’t be but that was completely my own fault. By his look and his conversation, I’d sort of assumed he was too. Big mistake; never judge a book by the cover! He recoiled as if I’d thrown my beer over him and I could see him struggling to remain politically correct:

“ Uhm…yeah, well you see…I didn’t realise…uhm… no I can’t do that, I’m sorry. See you around.”

Two immediate confidence points lost right after the look he gave me and one more after the excuse and I felt as though someone had hit me with a sledge hammer. I was furious but not at the fact that it actually was a problem; that’s a risk we all have to live with but at the lily-livered, cowardly response! This was a guy who had lived in Amsterdam for most of his life; was not much younger than me and must have lived through the HIV/AIDS years and yet he couldn’t get away fast enough, despite apparently finding me sexually desirable just five minutes before. Talk to me damn you!

Only five bonus confidence points left and they were barely keeping me from running out of the bar in hysterics. I decided to wait another half an hour to see if internet guy showed up and had prepared every available barrier to that being a potential disaster too. This time, I would ask him right out first but even then I knew that I’d still have to confess sooner or later. The eternal optimist kicked in then and the third beer was ordered. I was feeling somewhat woozy but nevertheless perversely proud of myself. I hadn’t always disclosed at the right time and realised that I’d overcome a subconscious barrier without really trying. I felt I’d be telling every time from now on; not that the opportunities were falling at my feet but there you go, three beers can work wonders and blunt edges.

It was getting busier but it remained the same eclectic mix that I was comfortable with. I accidently caught the eye of the younger guy from earlier but this time my lip curled first and he got ‘the look’ full in the face. Revenge is a sweet bitch, however small the victory.

Suddenly my sixth sense alerted me to the fact that I was being watched. It was a guy at the other end of the bar and he was staring unashamedly. Not bad looking, if a little worn around the edges. Now I knew I looked more than a little rough around the edges too, maybe there was a match here. I casually picked up my glass and putting on my slightly tipsy, ‘come hither’ look, stared back, more meaningfully. I think the penny dropped when his head suddenly lolled forward. He recovered quickly but the glazed eyes gave him away and when he dribbled as he leered at me, I got the message; he was completely out of it. Another point lost; I was being seduced by someone who needed to be blotto to do it; great boost to the ego that!

Okay, enough already. I looked at my watch and realised I’d been there for less than two hours. I got up, put on my coat and headed for the exit. Of course, internet guy chose that very moment to arrive and despite looking me full in the face, he walked right on by. With my remaining confidence points falling to the floor like leaves in autumn, I stalked out and went home.

It was okay, really; c’est la vie. It sounds like a good old, self-pitying rant but the evening had actually been good for me and I quickly realised it. I’d confirmed my place in the world at that snapshot in time and was okay with it. You’ve got to laugh at life sometimes, because it can never be a Hallmark greeting card: it wouldn’t be so interesting if it were.

I think all of those of us living with HIV have mixed feelings about problems relating to aging. On the one hand, aging means we're still here to have those problems, and who would have expected that twenty years ago? On the other hand, we do seem to get some of these problems a bit earlier than others and we are constantly confronted with the puzzle about whether our symptoms are due to age, HIV or our meds, or some terrible combination of them all. 

I just went through that experience where ENT progressed from a mobile tree-like creature in the Lord of the Rings series to an Ear, Nose and Throat specialist. That's quite some evolution! And, as an aside, the experience allows me to marvel at the accessibility of these specialists in our system, at least for people in major urban centres like where I live. And all covered by medicare, too. 

I got this referral from my own doctor for a couple of reasons. First, I have been having some sleep problems, like falling asleep during meetings (good thing I'm not an MP!), although I must say that I tend to have enough awareness of the conversation to be able to add my two cents worth when called upon, or at least I like to think so. So my ENT had a look at my palate and related parts and I don't seem to have any structural difficulties that would lend themselves to sleep apnea. I will just have to work on my habit of staying up too late and trying to get up too early. 

The second problem is one you might want to read about when you are not eating, if you're at all squeamish. I have a problem of accumulating ear wax. This, to the point where I actually had a blocked ear for several days when I visited Prince Edward Island last summer. There is nothing more annoying than the ups and downs of air travel without really being able to clear your ears, or the surreal half-heard experience of the world around you when you really weren't expecting it. 

I have had advice over the years about how to deal with this or how to prevent it. I do not use Q-tips (or generic cotton swabs), as I know those are verboten. I have used a little peroxide to try to dissolve and clear wax once it has built up, but this has limited efficacy and I even managed to burn the skin around my ear with peroxide just before my vacation, being so desperate to clear the wax that I repeated the procedure too many times. 

I've also been told that putting a little drop of oil in my ear will help keep the wax from accumulating…and the suggestions have been as diverse as olive or mineral oil. The ENT tells me that it may succeed in softening the wax that is there, but will also add to the blockage, at least temporarily. 

So today we did the old fashioned old man solution to the old man problem: giant metal syringe with warm water injected into the ear until the wax "plug" (anyone suppressing a gag about now?) popped out. Repeat for ear number two. 

What a relief as I head off on another plane trip to go to a meeting out of town! Thank goodness for the old ways as solutions to the age-old old age problems!