Newly updated US treatment guidelines are recommending antiretroviral treatment for all people with HIV infection, rather than starting at a particular CD4 range. But for those about to start treatment and their doctors, it’s not quite that simple; the strength of the recommendations varies by category of patient. Here is how a simplified scale looks:

• CD4 count less than 350 – strong recommendation
• CD4 count 350 to 500 - strong recommendation
• CD4 count over 500 – moderate recommendation

Regardless of CD4 count, initiation of ART is strongly recommended for individuals with the following conditions: pregnancy, a history that includes an AIDS-defining illness, HIV-related kidney disease and HIV/hepatitis B virus (HBV) co-infection. The guidelines also include an early treatment recommendation for anyone at risk of transmitting HIV to partners.

You can read a summary of the recommendations, including changes to existing guidelines, here or read the  full guidelines here.  

In contrast, recently issued draft British HIV Association treatment guidelines continue to recommend treatment when the CD4 cell count falls below 350, although treatment may be started earlier in people with hepatitis B or by people concerned about the risk of transmitting HIV to partners.

Canada has no national guidelines at present, a reflection of our provincially administered healthcare system, but our practice tends to follow the US guidelines.   BC and Quebec have their own guidelines.  But it’s likely that these new US guidelines will be influential in affecting treatment decisions here and around the world.

In Ontario, the advice you will receive currently depends, at least to some extent, on who is your doctor.  Some (many?) doctors are now suggesting treatment immediately on diagnosis, with the consent of the patient, of course. Others are suggesting holding off.  But clearly there has been a move towards earlier treatment for some time, driven in part by the evidence of better clinical outcomes   for those who start earlier, and in part perhaps by concerns about the perceived need to curb secondary infections that the treatment as prevention advocates frequently cite.  More on that later.

The issue of when to start treatment has been controversial. Previously, for instance, the panel that decided on the US guidelines was divided.

There has been little reaction to the new US guidelines from the Canadian HIV community to date.  But HIVers from Australia, in the form of NAPWA (National Association of People Living with HIV/AIDS) were quick to state their position.  In a March 28 statement, NAPWA president Robert Mitchell said “It is increasingly clear that untreated infection is bad for the health of people living with HIV, whether their infection is recent or long-term. We also think that people with HIV will value the added benefit of being on treatment in helping reduce the risk of transmitting HIV to others, when used with other proven prevention measures like correct and consistent condom use.”

This two-pronged rationale for earlier treatment contains elements which have been troublesome for people living with HIV in the past.  Over the years, there have for instance been issues raised about the potential side effects from long(er) term exposure to HIV drugs - longer term at least than if treatment were delayed.  Informed consent has also been an issue for some HIVers – nobody wants to be persuaded to start treatment when they are not ready for making that decision. But on this latter point the new guidelines are clear; “patients (who start) ART should be willing and able to commit to treatment and should understand the benefits and risks of therapy and the importance of adherence. Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy on the basis of clinical and/or psychosocial factors.”

The longer-term exposure to side effects concerns?  I raised this issue with Dr Julio Montaner, a long-time early-treatment proponent, when I interviewed him for PositiveLite.com earlier this year.  Here’s what he had to say about that. “There is no doubt that antiretroviral therapies have improved dramatically. They are simpler, safer and better tolerated. No doubt about it.  Are they perfect? No they are not….However, if we are having a discussion here on whether starting treatment immediately or on a deferred basis, the gap between those two decisions is somewhere in the order of months to a couple of years. It varies from person to person but when we’ve done studies, the rate of CD4 decline in an untreated person is somewhere between 60 and 120 cells per year. If somebody today says ‘no, I’m going to wait,’ what I say is ‘sure, you can defer antiretroviral therapy, no problem, we are not forcing anybody to start treatment.’ What we are saying is let’s have a discussion."

For an expert narrative on the new US guidelines, I interviewed CATIE’s Sean Hosein last week.  He’s an acknowledged expert on treatment issues and I wanted to gauge his feelings on the impact of the new guidelines for Canada.

Sean cautions against interpreting the guidelines as saying that once people are diagnosed they should start treatment then and there. “What this means” he says ”is that there is an opportunity for doctors and people living with HIV to start the discussion about therapy. Given the therapy that we have today, people are going to be taking it every day for the rest of their lives,  and so people have to be prepared for this – ready, willing and able.”

Do the new treatment guidelines represent a major change? Sean thinks so. ”It’s a major change compared to ten years ago, even five years ago, when they were saying ‘let’s wait ‘til the CD4 counts fall’. But what’s happened is that they’re finding that HIV just doesn’t affect CD4 counts. It causes inflammation inside the body that affects major organs like the brain, the heart, the lungs, the kidneys, the liver, the bones  - and so that’s why there is a push to start treatment earlier.”

I asked Sean to what extent the treatment as prevention arguments – which revolve around, in part, reducing the possibility of secondary infections by suppressing viral load to undetectable levels – might have had on the US decision to recommend starting  treatment earlier.  “I think it’s a mix of two things”, says Sean of the new guidelines. “It’s a mix of trying to do the right thing for the individual person living with HIV and also trying to do something for the rest of society in order to reduce the risk of transmissions.” But  of treatment as prevention, Sean cites the cautions in the guidelines about interpreting HPTN 052 results (the much-publicized study released last year which saw a 96% reduction in the risk of HIV transmission in heterosexual sero-discordant couples) too broadly, noting in particular the lack of data relating to MSM (men whoi have sex with men) , an issue discussed in my interview with CATIE’s James Wilton that you can read here.

On the side effects issue, Sean says the environment has changed. ”That argument, I think was important in the 1990’s and maybe ten years ago when the drugs that were used were much less tolerable.  With the drugs that are commonly prescribed today, the regimes are simpler.  There are side effects but they are generally mild and they tend to go away.  It’s true that people haven’t been on the latest drugs for fifty years so in theory there may be problems in years to come. . . . We need long-term studies to monitor people and those studies are underway.”

I asked Sean if the new guidelines are big news for the HIV community.  Sean thinks so. “It’s about strengthening doctor/patient relationships. I would encourage people who have recently been tested to see this as an opportunity to speak to their doctor about starting treatment early.”

Does he think the US guidelines will shift the Canadian response to HIV infection?  Says Sean “I think it will, because it’s good for people living with HIV. It will keep them alive longer.  It’s a good thing.”

I think so too.  Starting treatment earlier is likely a good thing for many people.  Whether the new US guidelines are driven by a desire for better clinical outcomes for people living with HIV or reflect treatment as prevention policies, or both, is almost immaterial.  I say almost because many of us have been vocal about our concerns surrounding treatment as prevention and we are cautious when some of its key tenets appear to go main-stream. But things have changed. Our knowledge of disease progression has changed. Treatments have changed. My own opinions have changed. So yes, I’m with the US on this one.

Let’s hope that Canada follows suit. 

Hi, my name is Wes and I’m almost three years old!

Ok, that’s not exactly true, my body is 36 years old. However the person everyone knows as Wes has existed for only about three years. You see, I identify as transgender and spent much of my life living, loving, socializing and interacting as a woman.

When I was born, I’m sure the doctor said “Congratulations, it’s a girl” and from that perspective the doctor was correct. My body was born female, two X chromosomes and everything (and before you ask, yes it’s been checked. I really do have XX genetics) and as such, I was raised and socialized as a girl. Well, mostly as a girl anyway.

In many ways, I was lucky in that my parents by and large left me to my own devices as I was growing up. They let me hang out with whomever I wished (boys for the most part) and I was expected to do all manner of tasks around the house, from getting the firewood to mowing the lawn when I was old enough. I was the oldest of three kids and we were expected to help out around the house, period. It didn’t matter that the youngest child was male; I was expected to learn how to help around the house and do all kinds of useful things from starting a fire in the fireplace to where the dishes go when they’re dry. In fact, all the kids (three of us in total, my youngest sibling being my brother) were expected to learn these skills as my parents simply considered them the price of living in the household.

I would like to say that I had an idyllic childhood, but I’d be lying through my teeth. My mother drank and my dad worked, a lot. Life was tumultuous at best, and downright nasty at its worst. I suppose it didn’t help that I was dealing with ADD (something I didn’t find out about till I was in my 20’s) and that as far as my parents and the school system were concerned, all I had to do was pull myself together and BOOM, all would be well.  If only it were so easy.

I spent my childhood, and in fact a large portion of my adulthood, thinking there was something fundamentally wrong with me. I knew I wasn’t like the other kids around me, and it wasn’t just because I wore glasses and had a heart condition. No, I knew there was something fundamentally different about me; I just couldn’t put my finger on it. I was pretty smart, loved to read, hated school and had a hard time physically keeping up with the other kids at times; however that wasn’t it.

As I grew older, I left the small town I was raised in and landed in Toronto, my own personal City of Hope.  It was the first time I’d ever had exposure to the ‘rainbow’ community and boy, was I shocked! I saw other girls who dressed like me, who seemed to think and move like I did.  I was able, at least on the surface, to see myself mirrored in faces around me. The tough looking butches that strutted down the street, the leather clad dykes that hung out in bars resonated in very deep places within me.  I felt like I had come home…and yet, there was still something I couldn’t put my finger on.

Looking back with retrospectively perfect vision, I can see that what wasn’t resonating was the fundamental acceptance these women had of their biological ‘woman-ness’. Granted, like every female growing up, they had absorbed images of what was acceptable and what was ‘allowed’ with respect to being a woman in society however these women had stepped outside those boundaries. By the simple act of being in love with other women, they had begun to disregard what society said was acceptable and carve their own paths. This was what appealed to me; this sense of self determination.  These women (because let’s face it, the gay men scared me for no sensible reason) embodied the boldness, the fearlessness and the sense of adventure that I wanted to have or rather, that I did have but needed to become comfortable with. Seeing these women live their lives gave me permission to start living my life the way I wanted. 

There was only one, small, tiny problem. You see, I wasn’t exactly consummately sexually attracted to women. Fact of the matter is, I rather liked men. I liked their smell, their bodies and the general way they carried themselves. I felt at home with men, comfortable and in many ways, felt like I belonged. You think this would have set off warning bells right? No such luck. I tried very hard to fit myself into the straight girl mold while at the same time, to others I looked more and more like a butch lesbian with each passing day.  I didn’t know it, but I was setting up an internal dynamic that would take nearly 14 years to resolve.

to be continued . . . . 

Wesley (or Wes as his friends call him) is a 36 yr old transman who lives in Kitchener, Ontario. When he’s not busy parenting his 6 year old son, Wes is out in the community speaking to students about his life and experiences as a transgender person. Using a combination of wit and facts, he invites his audiences to walk with him and learn about how he interacts with gender and how they can as well. 

 

Well, since a certain "Pierre Poutine" has been in the news of late, I have finally decided it is time to give in to Bob's persistent exhortations to write about this gooey delight we know as poutine

I say "we know" rather loosely, because I suspect I am about to introduce you to some incarnations of poutine that do not resemble the dish you might love to "dis". Oh yes, there are many forms of poutine, and I suspect that the ones seen beyond the borders of Québec are but pale imitations of what they might be. This is a story of what might be.

Yes, every small greasy spoon and hamburger joint here has its version of poutine that follows a pretty basic recipe: fries, gravy and some kind of cheese (curd if you're going to be authentic, grated if you're not). But you have to step over to the specialists if you are to appreciate the variety that can be poutine.

One such specialist is La Banquise. A staple of the Plateau Mont-Royal (one of the coolest neighbourhoods on the planet, we are told), La Banquise offers no fewer than 28 versions of poutine on its menu, often drawing a crowd such that you will need to wait in line to get in. Believe me, it is worth the wait, as the poutine taquise (with guacamole, sour cream and fresh chopped tomatoes) will attest.

I recently discovered a new kid on the block, at least one that had recently opened a branch on a block more easily accessible to yours truly. Poutineville bills itself as "poutine reinvented" and you will see why when you visit their lovely website. My recent visit led me to bring out my creative side to make my own poutine from the checklist menu, while my companion chose from the pre-set selections. A little mix-up gave me the form of potatoes he had ordered, and vice-versa, but I have to say that I thoroughly enjoyed my creation of "patates écrasées" with chicken, brie and a lovely wine sauce. Oh yes, this experience took poutine up a notch.

Higher up the old cuisine chain would be the higher-end restaurants and their forays into poutine. Le Canard Libéré and Au Pied de Cochon serve classic-looking poutines, but the fries are cooked in duck fat, making them particularly special. There was even a rumour once of the chef of Toqué! having put together a lovely poutine featuring foie gras, but you won't find this on their regular menu. Not even the little sister of Toqué!, the Brasserie T! in a box on the sidewalk next to Place des Arts lists poutine, despite many dishes accompanied by fries.

Still further up the chain, an experiment by award-winning chef Martin Juneau of La Montée de lait. I haven't tried this and it looks like the restaurant may indeed be closed, but I have managed to capture a still photo of his "poutine jenga" and a link to a short video of him explaining his creation to Urbania magazine.  Even if you don't speak French, I dare you to watch his short video and then tell me you wouldn't want to have a taste of whatever he wants to dish out.

So the question, my friends, ends up being not "Is poutine worthy of my appetite?", but "Is my appetite worthy of poutine as it can be?"

So I am writing from my sickbed... or rather my sick couch.  I forget at times that even though strong, I am not infallible.

When the body says rest, you rest.  It’s just that simple.  But it doesn’t have to be a depressing time.

Here is my favourite pick of five movies to watch when down for the day!

5 - Priscilla Queen of the Desert 

It’s fun.  It’s camp.  And I can go in and out of consciousness and still know all the lines and can see the picture with my eyes closed.

4- Kung-Fu Panda I & II

Ok.  So this is two movies, not one.  I normally can’t stand Jack Black, but as a pudgy panda who gets banged around, he’s charming.  Normally sequences of these sort of cartoons are not the greatest, but watching them back-to-back it feels just right!

3- Horrible Bosses  

Hilarious!  Loved it the first time, and still doesn’t get old.  The little guy, Charlie Day, steals many of the scenes he’s in.  Some great actors play parts in unconventional roles. 

2- Date Night 

They just make me laugh.  I have no idea what the story is most times as I lose track of the plot through waves of headaches or nausea but it still doesn’t seem to matter.  I hope Tina Fey and Steve Carrel do a sequel or another movie together.  Plus Mark Wahlberg – still as hot as ever!  I seem to always pay attention when he’s on – ain’t that funny! ;)

1-     The Italian Job  

Ok.  It’s not a funny one.  But stuff goes fast and there’s Jason Statham, Ed Norton....and OMG Mark Wahlberg!!  LOL!  It’s just occurring to me now I think I have a thing for him when I’m sick.  How funny! 

Again the plot seems of little importance but everything is moving and stealing and cunning and blowing up. I just don’t seem to care.  That and the mini car chase reminds me of the time I got that ticket from the police for using a rental mini Cooper and... Hmm... perhaps I should save that story for another day!

Now if they were to come out with a comedy movie with Mark Wahlberg playing a shirtless nurse, I’m sure I’d feel better in no time!

I didn’t know one person who was HIV-positive before I walked down that long hallway to get the results of my recent-exposure HIV test. I didn’t know one person who was HIV-positive before I made a decision, on December 18, 2011, to have unprotected sex, based on my assumptions about someone’s character instead of my knowledge of their status. But everything changed for me on January 24, 2012. On that day, the answer I have given for my entire life - that I’m negative - changed.

Hello, PositiveLite.com readers. I’m Josh Robbins. I’m 29-years-old, I live in Nashville, Tennessee, and I just found out that I’m HIV-positive.

Growing up in a small town in western Tennessee, I had big dreams. I was very active in my non-denominational church—a leader in the youth group. I loved playing basketball and found tremendous comfort performing community theatre on a massive stage. Both socially active and educationally grounded, I felt invincible, that the world was my stage. 

Yet I knew at a relatively early age that something was a bit different for me — that I was attracted to men. But if this was the worst thing about me, I could keep it quiet from my friends and family. Actually I was quite great about leading a double-life, even when I moved to New York City a month after graduating high school. I was free, I thought.

It was in New York that I was first openly introduced to safer sex. I was in a group discussion about sex and I was asked to participate in a game where I had to name a condom. It was uncomfortable but amazing to be able to have a dialogue about something that was never really discussed earlier in my life—sex. I named my condom “Camouflage” because “nobody would see me coming.”  Of course, I realized I was a natural at comedy. Or so I thought.

But after living in the Big Apple during September 11, 2001 and its aftermath, I decided to move back home to Tennessee. It was at that time that I realized how extremely close I was to my family. My sister became my best friend.

Because of my closeness to my family, and because of my ability to allow the world to be my playground, I made the decision at age 25 to come out as gay to my family and every one of my friends. But I revealed the news in a very matter-of-fact way. I never asked for their approval, because I felt I didn’t need it. I took the power of the conversation and said to every one of them that if they couldn’t or wouldn’t still love me, then I would choose for them to not be in my life. It was sharp, I must admit. But it was how I felt.

Almost every important person to whom I came out to as gay remains close to me to this day. Little did I realize at that time that the power that I’d mustered during those conversations would again be tested when I decided to reveal my HIV status.

The words that I heard when I got my test results - “It is a positive viral load” - still remain ingrained in my memory.  It’s very ironic how six simple words could literally take the breath out of me, even though I’d prepared for the possibility of this news for over three-and-a-half weeks, while waiting for my test result. You see, I’d been very active in local HIV awareness campaigns. I’d become the poster boy (literally) for an HIV vaccine study, with my face being on club-goers’ bathroom walls, beaming awareness and activism, in a very visible campaign, educating others about safer sex.

But the message didn’t seem to affect me personally. I thought I was invincible. And now I’m infected.

I felt alone—not knowing even one person who was HIV-positive. I felt scared and I didn’t want to die. So I made a decision. I would not allow myself to go back “in the closet” because of my status.

With this determination and personal decision not to remain silent about my status, I wondered what it would be like for others to actually hear the words from the hospital staff that I was either negative or positive. So, I armed myself with my phone camera and documented the long walk from my car to the actual clinic, keeping the recording going in my pocket. This was really important to me—documenting and recording the experience that so many fear or refuse to really consider. If I heard the news that I was HIV-positive, I wanted to both educate and make real the process others have, will or, hopefully, won’t go through. [You can view Josh’s video made on the day he got his test result at the end of this article. — Ed.]

Then, two weeks after I got my HIV-positive test result, I bought the domain imstilljosh.com.  The decision to start my blog at this site was simply that I wanted a place to put the video online, as well as be in control of the message that others may or may not hear about me in my hometown. I wanted to control the release of information and lead my personal narrative. Within three hours of the purchase, I wrote a very simple blog—“I’m Josh. I’m HIV Positive. So What? I’m Still Josh. You still be YOU!” And I posted on my blog the video of me going to the clinic to get my test results.

Simple enough, right? Well… not really. I had to get the word out that I had a blog, so I made a very simple status update on my personal facebook – just the link to the blog. I guess it went well—the blog had over 1,800 views within 24 hours. I don’t even know 1.800 people, let alone have that many virtual facebook friends. Well, the cat was out of the bag—and it feels great!

My thinking is pretty simple—the world continues even though I’m HIV-positive. My cell phone bill is still due at the end of the month. And if I don’t work, I can’t pay my car loan. But, I’m changed. I’m changed not only because of my HIV status, I’m also changed because I now realize that, before I became infected, I was mistaken in not allowing the message about HIV prevention to impact me. I’m also changed because I have a love for the other gay men in my city who also believe that they’re as invincible as I once thought I was.

So the journey starts, the fight continues, and humor is how I’ll continue to make it through. When things get stressful or people start acting crazy around me, I simply say. “You’re raising my viral load!” They get shocked; I laugh.

Because I blogged openly and candidly about being HIV-positive, another positive guy here in town made a video announcing his status that I posted on my blog. And more are on the way—the emails are rolling in from other HIV-positive men in the area willing and ready to share their stories as well. It’s all quite inspiring.

I’m still Josh. You still be YOU! And check out my blog imstilljosh.com.  http://imstilljosh.com

You can also follow Josh on Twitter @imstilljosh and friend him on facebook www.facebook.com/joshuarobbins 

Images courtesy of Out & About Newspaper". www.outandaboutnewspaper.com

Nineteen years.  My god!  I know this place well.  St Michael’s hospital in downtown Toronto is a bit of a labyrinth – a rather decrepit building comprised of four wings and numerous tunnels. Having visited almost every department but maternity in my time, I know this place like the back of my hand. I feel almost at home here.

This Wednesday morning I have a ten o’clock appointment, but I’m early so I sit in the fourth floor Positive Care waiting room looking around.  Beige walls, beige linoleum, purple-flowery chairs, a few bland prints on the walls.  The overall impression isn’t terrible but clearly a gay designer wasn’t involved either.  It’s hospital blah, but in fairness a cut above some other waiting rooms in the hospital,

The fifteen chairs are arranged in two lines facing each other, which gives you an unparalleled chance to stare at your fellow patients and wonder at their stories.  Only two chairs are occupied right now – one by a young and stylish Asian, obviously gay young man in sunglasses (surely no need for those here unless it’s his idea of disguise.) In the other occupied chair sits a man who I shared the elevator up with and I would have guessed was going anywhere BUT the Positive Care Clinic.  He looked too straight, too ordinary, and with too bad hair for that. But he is a patient and there he sits waiting for his HIV doctor, just like me. Score zero for my poz-dar.

No women here today but there often are.

Time was when there was a little old lady who used to hang out in the Positive Care waiting room, a candy-striper (as opposed to a candy stripper)  I think they call those volunteer auxiliary people, dispensing tea, cookies and chat. It was nice, but left me with the impression that we were deserving of sympathy, so I wasn’t unhappy to see the service go.  Plus I don’t like tea much.

Like I said, I’m early which is generally a mistake as it seems to make no difference what time you arrive, you still have to wait.  I did get a cheerful "hi, how are you?" from the cute male receptionist when I arrived, though, which is a plus.

I don’t have to wait long today.  Nurse Rachel ushers me in to the inner sanctum – she’s newish and cheerful and polite.  I’m weighed and my blood pressure is taken  - 100 over 60 she says, that’s good.  Must confess I never bothered to learn the meaning of those numbers, but if Nurse Rachel says it’s good, that’s good enough for me. She asks me only a few questions:  have you had your flu shot, how have you been since your last visit, have you  had any broken bones (whaaa?) And then she’s out of there saying that Dr F, my HIV doctor for the last nineteen years, will be with me in a minute.

And he is. He’s a short Asian man with thick glasses.   He’s a no -nonsense type, is my doctor, not great on the bedside thing, but a real wiz, as far as I’m concerned, when it comes to HIV, and that’s what matters most to me. We don’t exactly have the ideal relationship in that treatment decisions tend to be ordained rather than negotiated, but I’m OK with that.  Treatment isn’t my strong suit, so my strategy has always been to favour the knowledge that comes from his years of medical training plus hands-on experience in one of the country’s busiest HIV clinics over my thumbing through back issues  of Readers Digest So I put my trust in him.  Given that he’s kept me well for nineteen years through thick and thin, I have accumulated a lot of faith in him.

He moves right away to scrambling through my chart. He’s flipping pages like mad, transcribing numbers to my visit records.  First things first; my CD4 is 733, down from 800 last visit (no big deal)  my viral load is undetectable. I, wanting to give at least the appearance of being a good patient, take notes.

Now I am not someone who keeps spreadsheets of my numbers – that veers far to near the good patient category for me – but I do write things down.  So I have this tatty piece of paper which records the meds I’m on now (because I can never remember their names)  and my key numbers since May 2007.  Who knows where the previous sheet is now. Anyway, I dutifully write down my numbers and a few other things he is saying.  He is working on something new now, jotting down figures which he says will give me my "risk calculation".  Risk of what, I wonder, but he’s buried in his numbers for several minutes and interrupting him doesn’t seem wise.  Eventually he looks up.  “You have a moderate chance of a heart attack” he says. "What does that mean?” I say.  It means, he explains,  that based on my weight and cholesterol and smoking record (I don’t smoke) and other factors, I have a 15.6% chance of a heart attack in the next ten years.

I’m thinking “those odds aren’t bad”. Probably not bad enough to make me want to walk -  briskly – for one hour a day – that he is now suggesting I start doing.

Discussions of my mortality, out of the blue, are a new one for my clinic visits. It throws me a bit. But then we are off on meds talk.  It’s all about my favourite side effect, peripheral neuropathy and whether it's responding to treatment and does it feel touchy or stingy and whether I should be taking gabapentin AND nortriptyline for it or just gabapentin. (Clearly I lean towards the less pills rather than more, and since these both are antidepressants besides their neuropathy-busting abilities, I’m wary.  I say "I’ll see", which usually means I won’t.)

Doc’s getting more chatty by the minute though and throwing out tips as he does a quick go round of my body parts as I sit on his examining couch.  Eat more fish. Cut out fatty food.  No pastries. (No pasties? Is the man crazy?) But then he follows it up with a compliment.  “Honestly, you’re doing pretty well for your age” he says.

And then we’re done. New scripts written, appointment made for four months time, see you next time.

Overall I rate the experience quite good. It’s an instutionalized experience, it’s true, which comes from my choice of a clinic rather than attending a private practice.  But the clinic model serves me well.  This one has a multi-disciplinary team that seems to works well together. In my time, I’ve consulted with their nutritionist, their social worker, their psychiatrist, their resident  pharmacist and their clinical trials specilaist.  The nurses are great too. In a way, it's a model of how things should operate.

 Now if I could just be a model patient.