over several doctors agreeing to see patients, but even though it is Title III, there are no provisions for nutritional services including food or counseling that I have been able to uncover. To overcome this, I solicit representatives for supplies to at least give the patients something to try and use for a limited time. We are also reaching out to some of the ministries here that are active in HIV/AIDS support. We hope to work with the agency that has Ryan White money to improve how they are currently disseminating their grant funds and to also add a non-profit foundation at the clinic to help cover patient needs."

Who is your best ally? The medical staff she works with-- on the days that she is not available in the clinic, they still keep nutritional services in mind. "They will track a patient that I need to call to schedule an appointment with. Both Dr. Jemsek and our physician assistant (PA) incorporate nutrition as part of routine care for patients."

What differences exist between current clientele and that of the HIV+ person in the early 1980s? "Well, for the most part patients aren't dying as quickly.  In the 80's I didn't know anything about BIA, DEXA or anabolic programs.  Wasting is still prevalent and unless a patient has access to some type of body composition testing it may be overlooked.  Nutritional status of patients is still compromised and not necessarily well addressed in all situations.  The lipodystrophy syndrome has certainly made things more interesting and complex - I see a lot more lipoatrophy with and without central shifts than dorso-cervical relocation. Using the DEXA scan has been interesting because even with facial/peripheral fat loss, there is some degree of central shifting seen in a patient whose overall fat percentage is very low. I counsel a lot more patients on diabetes and cardiac issues also.  Patients are more complex in that they can have 3 or more chronic conditions going on at the same time - diabetes, hyperlipidemias, Hepatitis C co-infections, osteoporosis etc."

Ms. Lichtner also notices differences between men and women. The women tend to have more central deposition than the men, and complain of increasing breast size, fat pads behind the neck, etc.  She does not see facial wasting as prevalent in the female population. She also finds most of the females remain working and are also caregivers.

Is someone involved in program operation actively involved with the local HIV/AIDS Health Services Planning Council? Yes. The PA that works for the clinic is currently working with MAP. They have the Ryan White money for the Charlotte metro-area - to improve the services they are supposed to provide.

Do you participate regularly in HIV/AIDS networking groups? No, due to the fact that there is little networking amongst the groups. There doesn't seem to be any interaction or coordination between the support ministries and Ryan White funds - no AIDS Service Organizations. Ms. Lichtner is active and supports RAIN (Regional AIDS Interfaith Network) in Charlotte.

What have you found to be most useful in helping to keep up with the current research on nutrition and HIV? "I joined the HIV/AIDS Dietetic Practice Group (DPG) of the American Dietetic Association - there is a quarterly newsletter and an email listserv that keeps me abreast of hot issues.  I also read the Nutrition and Complementary Care DPG newsletter and use the Natural Medicine database website to help wade through all the information on nutraceuticals,  etc.  I scan the HIV Medscape website weekly and try to read NUMEDX and HIV+Plus monthly. I find that going to seminars and discussing/networking with other RDs, to find out what they do routinely, is also helpful."