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Ask Dr. Jeff

Spring, 2000

Question: I am a 40-year-old male diagnosed with HIV since 1992, and am looking for treatment information for peripheral neuropathy. I suffer from extreme pain in my legs, from the soles of my feet, up my legs. I am currently on a drug cocktail of Sustiva, Zerit (d4T), Epivir (3TC). For the neuropathy, I take gabapentin 300mg 12 pills per day with oxycodone sustained released 55mg/day spread out in five doses, for pain. I am interested in any information on mexiletine for neuropathy pain. Does mexiletine work on the same receptors as gabapentin? Could it/would it be a good replacement for gabapentin? Also any other treatment/drug suggestions for neuropathy would be greatly appreciated.

Answer: The cornerstones for the treatment of HIV-associated neuropathy, weak though they are, are removing any possible causative factors, treat with pain relievers, amitriptyline (Elavil, an antidepressant), and gabapentin (an anticonvulsant). All of the "D" drugs -- ddC, ddI, and d4T -- can cause neuropathy, (as can HIV infection itself), so replacing d4T, with another antiretroviral, if possible, may be of some help. There are some ongoing studies evaluating mexiletine (Mexitil), a local pain killer also used for abnormal heart rhythms. How effective each of the above drugs are and whether combinations might be additive is unknown.

There is also a neuropathy study ongoing at the University of Washington AIDS Clinical Trial Unit (ACTU) of lamotrigine, an anticonvulsant. (Phone 206-731-3184 for more information.) The ACTG has also conducted a study of nerve growth factor and found it to provide mild to moderate pain relief in some people with neuropathy. However, it is not yet FDA approved and is now primarily being developed for relief of neuropathy associated with diabetes. Also, some people have reported some pain relief using alpha-lipoic acid, which can be purchased at most drug and nutritional stores.

An excellent article reviewing treatment of neuropathy appeared in POZ this past year by Mark Mascolini.

Question: I am an HIV-positive native of another country, studying in the U.S. I am on Combivir and Sustiva. My problem, however, is that I will certainly die if I go back home on completion of my studies here. This is so because it is almost impossible to access these medications in my home country. Even the rich cannot keep to a recommended drug regimen since there is not the health infrastructure to support the administration of antiretrovirals. So, I am wondering if this situation can be grounds for me to seek asylum in the U.S. What would you advise?

Answer: The legal basis for asylum is a credible showing of past, or fear of future, persecution by the government based upon race, religion, nationality, membership in a particular social group, or political opinion. There have been successful asylum applicants from many countries based on sexual orientation and also HIV status. Homosexuals have been formally recognized by the Clinton administration as members of a social group for purposes of asylum, but you still must show fear of future persecution by the government. The class of being HIV-positive is less well established but has been recognized in some applications, but is not formally so designated as a social group. Most successful asylum applications filed by people who are HIV-positive have argued persecution based on both HIV status and sexual orientation. However, a few successful applications have been based on persecution based upon HIV status only.

The process of granting or denying asylum involves a great deal of discretion by the INS. You must apply within one year of arriving in the U.S. But, if you just recently became aware of the situation that would give rise to future persecution, you might be able to get around that rule. The U.S. government does not give asylum based on personal hardship, such as lack of medications to keep you alive in your home country, and in fact is fighting these applications rather hard because of the fear of the perception that this would "open the flood gates."

Other options would be to try to get a temporary employment-based visa, which does not require an HIV test, but you would have to have a cooperative employer and meet all the requirements associated with that visa. This approach can keep you here legally for a few years. In general, no HIV-positive people are allowed in the U.S. under any visa status, even tourist visas. The only exception to this rule is that spouses of U.S. citizens can apply for a waiver if they are HIV-positive. You must be able to show that you have private health insurance and will not become a public burden. (The U.S. does not recognize same-sex relationships in their definition of spouses, only legally married couples.)

This response is not providing you with legal advice, but only information. I would recommend you contact your local AIDS service organization and seek a legal referral. Most cities have a referral network for free legal consultation, for HIV-positive people. This area of law is very country specific.

Also, an excellent asylum resource for general and country-specific information, for both sexual orientation and HIV-based asylum information, is the International Gay and Lesbian Human Rights Commission. Their contact information is:

1360 Mission Street, Suite 200
San Francisco, CA 94103
Tel: 415/255-8680

Satellite Office:
IGLHRC c/o Human Rights Watch
350 Fifth Avenue, 34th Floor
New York, NY 10018
Tel: 212/216-1814

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We will answer all questions and print those that space allows.

Dr. Jeff Schouten is a former general surgeon who has been living with HIV for over 10 years. He has been co-chair of STEP's Scientific Review Committee for several years and contributes regularly to the STEP Perspective. He has also recently earned a law degree from the University of Washington, so HIV-related legal questions, as well as medical, will be accepted.

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This article was provided by Seattle Treatment Education Project. It is a part of the publication STEP Perspective.