AIDS Treatment News
July 4, 1997

Contents:

• New Standard of Care for HIV Disease
• Major Pediatric Study Stopped Early: Combination Treatment Better
• Saquinavir: Major Study Shows Survival Benefit in Treatment- Naive Patients
• HIV Resistance International Meeting: Summary on Web; Half- Day Meetings
• National Summit Meeting on HIV Resistance, July 17 -- By Telephone
• AmFAR Will End Support of CBCT Network, Begin New Clinical Program
• Internet Free Speech Upheld
• AIDS CARE Newsletter
• San Francisco, Healing Alternatives: Help Wanted, Also Directors, Volunteers
• California: AIDS Hotline Expands to Cover State, Increases Hours

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New Standard of Care for HIV Disease  by John S. James

Four documents released in the last two weeks have formalized a U.S. standard of care for HIV disease. These guidelines outline treatment approaches which are already in use by leading HIV physicians. Their official publication will greatly support efforts to improve the quality of HIV treatment for thousands of patients elsewhere in the medical system who have quietly been receiving seriously inadequate care. While not every physician will agree with every recommendation, these documents, and their reception so far, seem to reflect an unusually high degree of expert consensus on HIV treatment at this time. Three of the documents are from government agencies, and are therefore expected to have the most impact on decisions about what treatments will be reimbursed by third-party payers. The fourth, the result of an independent effort, organized by the International AIDS Society, USA, to develop recommendations for HIV care, is consistent with the government reports. The IAS document may have more distribution initially, because it has been published in JAMA (JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION), June 25, 1997. The four documents are: REPORT OF THE NIH PANEL TO DEFINE PRINCIPLES OF THERAPY OF HIV INFECTION, released by the U.S. Department of Health and Human Services. It was prepared by a panel of 23 experts chaired by Charles Carpenter, M.D., of Brown University. A companion document, GUIDELINES FOR THE USE OF ANTIRETROVIRAL AGENTS OF HIV-INFECTED ADULTS AND ADOLESCENTS, also released by the U.S. Department of Health and Human Services. These guidelines were developed by a panel of 24 experts chaired by Anthony S. Fauci, M.D., of the U.S. National Institutes of Health, and John G. Bartlett, M.D., of Johns Hopkins University. (Dr. Carpenter and one other panelist, Robert T. Schooley, M.D., of the University of Colorado, were also on the Principles panel.) Both of these reports were released as drafts for public comment; after the comment period ends on July 21, they may be revised before becoming final. It is unlikely that major changes will occur. 1997 USPHS/IDSA GUIDELINES FOR THE PREVENTION OF OPPORTUNISTIC INFECTIONS IN PERSONS INFECTED WITH HUMAN IMMUNODEFICIENCY VIRUS, published in the MMWR (the MORTALITY AND MORBIDITY MONTHLY REPORT, of the U.S. Centers for Disease Control and Prevention), June 27, 1997. This is the final version of these recommendations, which have already gone through a comment period. The recommendations were developed by a working group of more than 40 experts. ANTIRETROVIRAL THERAPY FOR HIV INFECTION IN 1997: UPDATED RECOMMENDATIONS OF THE INTERNATIONAL AIDS SOCIETY-USA PANEL, published June 25 in JAMA. These recommendations were prepared by a panel of 13 expert physicians, seven of whom were also on the NIH Panel to Define Principles of Therapy in HIV Infection. It would be impossible to meaningfully summarize these reports in a short article. But we can indicate what kinds of information they contain. (1) REPORT OF THE NIH PANEL TO DEFINE PRINCIPLES OF THERAPY OF HIV INFECTION outlines current scientific knowledge about HIV disease, and 11 principles on which treatment should be based. Each of the 11 is discussed in detail. Overall there are 28 pages of text, eight pages of illustrations and tables, over a hundred references, and a list of the names and affiliations of the panelists. Because specific guidelines such as particular drugs are not included, it is believed that this document will not need to be updated very often. The 11 principles are: Ongoing HIV replication leads to immune system damage and progression to AIDS. HIV infection is always harmful, and true long-term survival free of clinically significant immune dysfunction is unusual. Advertisement Plasma HIV RNA levels indicate the magnitude of HIV replication and its associated rate of CD4+ T-cell destruction, while CD4+ T-cell counts indicate the extent of HIV-induced immune damage already suffered. Regular, periodic measurement of plasma HIV RNA levels and CD4+ T-cell counts is necessary to determine the risk of disease progression in an HIV-infected individual and to determine when to initiate or modify antiretroviral treatment regimens. As rates of disease progression differ among individuals, treatment decisions should be individualized by level of risk indicated by plasma HIV RNA levels and CD4+ T-cell counts. The use of potent combination antiretroviral therapy to suppress HIV replication to below the levels of detection of sensitive plasma HIV RNA assays limits the potential for selection of antiretroviral-resistant HIV variants, the major factor limiting the ability of antiretroviral drugs to inhibit virus replication and delay disease progression. Therefore, maximum achievable suppression of HIV replication should be the goal of therapy. The most effective means to accomplish durable suppression of HIV replication is the simultaneous initiation of combinations of effective anti-HIV drugs with which the patient has not been previously treated and that are not cross-resistant with antiretroviral agents with which the patient has been treated previously. Each of the antiretroviral drugs used in combination therapy regimens should always be used according to optimum schedules and dosages. The available effective antiretroviral drugs are limited in number and mechanism of action, and cross-resistance between specific drugs has been documented. Therefore, any change in antiretroviral therapy increases future therapeutic constraints. Women should receive optimal antiretroviral therapy regardless of pregnancy status. The same principles of antiretroviral therapy apply to both HIV-infected children and adults, although the treatment of HIV-infected children involves unique pharmacologic, virologic, and immunologic considerations. Persons with acute primary HIV infections should be treated with combination antiretroviral therapy to suppress virus replication to levels below the limit of detection of sensitive plasma HIV RNA assays. HIV-infected persons, even those with viral loads below detectable limits, should be considered infectious and should be counseled to avoid sexual and drug-use behaviors that are associated with transmission or acquisition of HIV and other infectious pathogens. (2) GUIDELINES FOR THE USE OF ANTIRETROVIRAL AGENTS OF HIV- INFECTED ADULTS AND ADOLESCENTS have more specific treatment and testing recommendations. We cannot summarize the report here, but the headings and subheadings outline its scope: Introduction Use of Testing for Plasma HIV RNA Levels and CD4+ T Cell Count in Guiding Decisions for Therapy Established Infection --Considerations for Initiating Therapy in Patients with Asymptomatic HIV Infection --Initiating Therapy in the Patient with Asymptomatic HIV Infection --Initiating Therapy in Advanced HIV Disease --Special Considerations in the Patient with Advanced Stage Disease Interruption of Antiretroviral Therapy Considerations for Changing a Failing Regimen --Criteria for Changing Therapy --Therapeutic Options When Changing Antiretroviral Therapy Acute HIV Infection --Whom to Treat During Acute HIV Infection --Treatment Regimen for Primary HIV Infection --Patient Followup --Duration of Therapy for Primary HIV Infection Considerations for Antiretroviral Therapy in the HIV- Infected Pregnant Woman Conclusion Unfortunately these draft antiretroviral guidelines do not discuss treatment of children, leaving that for later. This report has 16 pages of text, 18 pages of illustrations and tables, and 34 references. (3) 1997 USPHS/IDSA GUIDELINES FOR THE PREVENTION OF OPPORTUNISTIC INFECTIONS IN PERSONS INFECTED WITH HUMAN IMMUNODEFICIENCY VIRUS is full of useful information, not only about preventive drug treatments, but also about food safety, pets, travel, childhood immunization schedules, and the cost of drugs and vaccines. Seventeen different infections and classes of infections are discussed in separate sections. Tables include: CD4 cell counts for children up to 12 years (which are different from CD4 cell counts for adults); drugs and doses for adults and adolescents, and for children; immunization schedules for HIV-infected children, noting where they are the same as for HIV-negative children and where they are different; and a summary of recommendations for preventing exposure (sexual, environmental and occupational, pet-related, food- and water- related, and travel-related). There are 27 pages of text, 18 pages of tables, and 24 references. (4) ANTIRETROVIRAL THERAPY FOR HIV INFECTION IN 1997: UPDATED RECOMMENDATIONS OF THE INTERNATIONAL AIDS SOCIETY-USA PANEL is a shorter document, 8 pages in JAMA, including 61 references, and tables. The headings and subheadings are: Scientific Rationale for Updated Recommendations Initiating Antiretroviral Therapy --When to Initiate Therapy --Initial Antiretroviral Regimens Changing Antiretroviral Therapy --Considerations for Changing Therapy --What To Change To Special Considerations --Primary Infection --Postexposure Prophylaxis --Perinatal Transmission Summary There are no major inconsistencies between these RECOMMENDATIONS, and the Federal antiretroviral GUIDELINES. There are minor differences; for example, note the following discussions from the respective sections on when to start therapy. From the IAS RECOMMENDATIONS: "Therapy is now recommended for all patients with plasma HIV RNA concentrations greater than 5000 to 10,000 copies/ml regardless of CD4+ cell count... Therapy should be considered for all subjects with HIV infection and detectable plasma HIV RNA who request it and are committed to lifelong adherence to the necessary treatment. For patients with low plasma HIV RNA levels and high CD4+ cell counts, therapy might be safely deferred in the short term with reevaluation of plasma HIV RNA level every 3 to 6 months. A small minority of subjects who may be true long-term nonprogressors or slow progressors might be identified with this approach... Therapy continues to be recommended for patients with symptomatic HIV disease or with CD4+ cell counts below [500], particularly below [350]. The latter recommendation is especially important in situations in which HIV RNA assays are not available." From the (Federal) GUIDELINES: "In general, any patient with less than 500 CD4+ T cells/mm(3) or greater than 10,000 (bDNA) or 20,000 (RT-PCR) copies of HIV RNA/ml of plasma should be offered therapy. However, the strength of the recommendation for therapy should be based on the readiness of the patient for treatment as well as a consideration of the prognosis for disease-free survival as determined by viral load, CD4+ T cell count (Table IV and Figure 1), and the slope of the CD4+ T cell count decline." [Notes: (1) Figure 1 from the GUIDELINES shows how the risk of disease progression depends on viral load and CD4 cell count. (2) Two viral load tests are now in common use in the U.S.: bDNA and RT-PCR. The tests are different; the values reported by the current PCR test tend to be about twice as high on the average as those reported by the bDNA test currently in use. That is why the GUIDELINES gives two numbers for starting therapy -- greater than 10,000 copies if the bDNA test is being used, and 20,000 if the result is from PCR. Each patient should use one kind of test consistently, to show changes in viral load; the two- fold correction factor is for averages, and would not be reliable for an individual, since the tests may respond differently to different strains of HIV.] Why are there two slightly different treatment standards, instead of one? Much of the reason is historical. The IAS panel started first, and released a draft of its guidelines a year ago, at the XI International Conference on AIDS, July 1996 in Vancouver. But that draft had been delayed for months by a publication embargo, and when it became public it was already widely considered obsolete, because its recommendations for treatment were not aggressive enough in light of new knowledge about HIV disease. The panel continued its work, and produced the current draft, which does reflect the new knowledge. Meanwhile, the U.S. Public Health Service, which often takes the lead on such matters, needed to establish its own guidelines process -- partly in order to develop consensus within the government on what treatment should be reimbursed. How To Get Copies of These Reports You can obtain copies of the three government reports by mail, from the HIV/AIDS Treatment Information Service, 800/448-0440 (the opportunistic infection guidelines need to be ordered separately), or from the CDC National AIDS Clearinghouse, 800/458-5231. In case you need the National AIDS Clearinghouse document numbers, they are D936 (the PRINCIPLES, and the GUIDELINES, in one package), and D938 (the final opportunistic infection guidelines, which are published by the CDC in its weekly journal, the MMWR, June 27, 1997). Note that the PRINCIPLES, and the antiretroviral GUIDELINES, are currently drafts, which will be superseded when the final versions are published in MMWR, probably later this year. The IAS RECOMMENDATIONS were published in JAMA on July 1, 1997, and could be found in a medical library. If you have access to the World Wide Web, you can get all four documents immediately. The PRINCIPLES and the antiretroviral GUIDELINES were announced in the FEDERAL REGISTER on June 19, and at that time they were released on the Web site of the National AIDS Clearinghouse, http://www.cdcnac.org, and also on the Web site of the HIV/AIDS Treatment Information Service, http://www.hivatis.org. On these sites the documents are published as "PDF" files to be read by the Adobe Acrobat(TM) reader -- a program which can be downloaded free for all common computers. Some Web browsers can open PDF files automatically. [Note: Some people have had difficulty using the PDF files, because of unfamiliarity with the computer procedures involved. To make these reports more conveniently available online, they have been converted unofficially so that they can be read directly on the World Wide Web; these versions are posted at the site of Healthcare Communications Group, http://www.healthcg.com. Here they can be read like anything else on the Web, with no need to download the PDF files or the Acrobat reader.] The opportunistic infection guidelines can be found at http://www.cdc.gov/epo/mmwr/mmwr_rr.html; this site has current and back issues of the MMWR, in the PDF format. The opportunistic infection guidelines are in the June 27, 1997 issue (volume 46, number RR-12). The IAS guidelines are currently online at the JAMA HIV/AIDS Information Center, http://www.ama-assn.org/special/hiv/library/j97list.htm. Public Comment Period Two of the Federal documents (PRINCIPLES, and antiretroviral GUIDELINES) were released in draft form for a 30-day public comment period. Written comments must be postmarked by July 21, and mailed to: The HIV/AIDS Treatment Information Service, P.O. Box 6363, Rockville, MD 20849-6303. Illustration -- Likelihood of AIDS In our print edition we reproduced a graph, "Likelihood of Developing AIDS Within 3 Years," which is Figure 1 in the antiretroviral GUIDELINES. This illustration would make an excellent poster or postcard to show the importance of getting medical care for HIV infection. It can be found through http://www.healthcg.com (we have not published the direct link, because the site is now being reorganized, and the link will change).

Major Pediatric Study Stopped Early: Combination Treatment Better Risk by John S. James

On June 26 the U.S. National Institute of Allergy and Infectious Diseases (NIAID) announced that it was stopping a clinical trial in over 600 children ahead of schedule, because those assigned to treatment with AZT plus 3TC did much better than those treated with ddI monotherapy. In this trial, known as ACTG 300, the risk of disease progression was reduced by about 70%, and the risk of death was reduced by about 80%, for those receiving the combination vs. those receiving the single drug. This result is mainly from children under 3 (who were analyzed separately), because there were far fewer cases of disease progression, and no deaths, in the children over 3, so reliable conclusions for them could not be drawn from this study. The children in ACTG 300 had symptomatic HIV disease, and little or no prior experience with antiretrovirals. Both treatment regimens were generally well tolerated. Those who received a third treatment, AZT+ddI, also did better than those receiving ddI alone. But there is less information about AZT+ddI from this study, since that treatment arm was closed early to new enrollment, due to results from an earlier study (ACTG 152) suggesting that ddI alone was comparable to AZT+ddI. The differences between the two studies, and the reasons for the apparently conflicting results, are now being analyzed. Meanwhile, the ACTG 300 Abbreviated Executive Summary concludes: "In symptomatic antiviral naive HIV-infected children, combination therapy with either ZDV [AZT] plus 3TC or ZDV plus ddI was superior by clinical and laboratory measures to monotherapy with ddI, and therefore should be the preferred initial treatment, particularly for children under three years of age." ACTG 300 began in July 1995 and was conducted at 87 medical centers in the United States; 65 of them were Federally supported (by NIAID, and by the U.S. National Institute of Child Health and Human Development), and 22 were supported by Glaxo Wellcome. Of the 596 children in the preliminary analysis which has been done so far, 42% were male, 63% were black, 22% were Hispanic, 14% were white, and 1% were from other ethnic groups. Only very preliminary reports of the results are now available, as the data analysis which ended the study took place on June 18, 1997 -- only eight days before the public announcement that the study was being stopped. More will be learned as further analysis is completed.

Saquinavir: Major Study Shows Survival Benefit in Treatment-Naive Patients By John S. James

The largest trial ever conducted in AIDS, enrolling over 3400 volunteers with little or no prior HIV treatment, found that the three drug treatment saquinavir (Invirase(R)) plus AZT plus ddC reduced disease progression or death by 50%, compared to AZT plus ddC, a result which was highly statistically significant (p=0.0001). Deaths alone were reduced by about 42 percent, but due to the smaller number of deaths, this result was not quite statistically significant (p=0.067). The trial, NV 14604, was conducted outside the United States by Hoffmann-La Roche, and reported to the investigators in a two-page executive summary; a more complete report is being prepared for publication. Among those entering the trial, the median CD4 count was about 200, and the median viral load was about 100,000. They either had no prior antiretroviral treatment, or no more than 16 weeks of AZT. The median time on study treatment was 14 months, and the median time of followup for clinical endpoints was 17 months. The saquinavir dose and formulation used was the same as that marketed until now in the U.S. This is the only trial to prove clinical benefit from using a protease inhibitor in treatment-naive (or minimally treated) patients; the other clinical-endpoint trials were all in volunteers who had been more heavily treated with antiretrovirals. Combination treatment including a protease inhibitor is already well accepted in the U.S. for initial HIV therapy; therefore, these results may have little impact on the U.S. standard of care. But they could strengthen the case for making sure that all those who need the accepted treatments have access to them. And in Europe, where many patients still start treatment without a protease inhibitor, this trial may change the standard of care.

HIV Resistance International Meeting: Summary on Web, Half-Day Meetings in San Francisco and New York

The important International Workshop on HIV Drug Resistance, Treatment Strategies, and Eradication was held in St. Petersburg, Florida, June 25-28. This highly technical meeting was limited mostly to researchers working in the field; information will be made available to the larger community through various media. We know of two rapid reports: A summary of the international resistance meeting will be posted in early July on the Web site of Healthcare Communications Group, http://www.healthcg.com. Anyone can obtain this summary without charge. A half-day seminar reporting on the meeting will be held in San Francisco on the morning of July 9, and in New York on the afternoon of July 11. Registration for each of these meetings is $125. For more information, call International Medical Press, 800/868-2022 or 404/233-6446. SCIENCE magazine published an article about this meeting in its July 4 issue.

National Summit Meeting on HIV Resistance, July 17 -- By Telephone

The AIDS Treatment Data Network and Project Inform will sponsor a meeting on HIV drug resistance, Thursday July 17, 8:30 a.m. to 4:30 p.m. Eastern time. It will focus on "protease inhibitor resistance and cross resistance; how current data on resistance affects guidelines for treating HIV; and what health educators need to know and communicate to their clients." Speakers will include leading HIV physicians, treatment activists, and researchers from pharmaceutical companies. This meeting will focus more on community education than on a reportback from the recent resistance meeting in St. Petersburg, Florida. The meeting (which will be held in New York) is full, but additional people can listen toll free by telephone. For more information, call the meeting hotline at 800/292-9605, 24 hours a day.

AmFAR Will End Support of CBCT Network, Begin New Clinical Program by John S. James

The American Foundation for AIDS Research (AmFAR) will end support of its Community Based Clinical Trials network at the end of the current three-year contract cycle in January 1998, except for funding to finish, analyze, and publish the trials still underway. AmFAR will begin a new clinical research program in which it will sponsor studies, but not be involved in their day-to-day management. AmFAR president Arthur J. Ammann, M.D., said the change is being made because "AmFAR felt strongly that at this point in the epidemic, it needed flexibility to put out requests for proposals for very specific areas. Continuing to study drugs for their effectiveness -- the kinds of trials being done by government networks and by pharmaceutical companies -- is very expensive and beyond the Foundation's capabilities." AmFAR has spent $30 million on CBCT trials since it started that network in 1989. Some of the 12 sites currently being funded also have other support from government or industry; others do not. AmFAR plans to start the new clinical research program with an RFP (request for proposals) issued in January 1998 for funding in July, and to issue new RFPs annually. This funding will be open to all qualified research groups, not only community-based groups. The kinds of studies which this program will fund "will be determined by outside advisory committees based on urgent research priorities in the epidemic." Grants will be investigator initiated and peer reviewed, and may be in the range of $150,000 to $200,000 for 12 months, renewable; they could be used to fund small, single-site proof of concept trials. According to Dr. Ammann, the total AmFAR funding for clinical research under the new program is expected to be comparable to what is being spent currently. In addition, AmFAR plans grants to community-based organizations, starting in January 1998, "for outreach and education activities...to enhance the recruitment and retention of individuals into clinical trials available in their communities." This program will focus particularly on outreach to disadvantaged groups currently underrepresented in clinical trials. Comment The AIDS community, including donors and treatment activist organizations, needs to pay attention to the development of the annual RFPs, and to the composition of the committees involved in selecting which clinical research will be funded. A critical role for medical research supported by public donations is to enable studies which are scientifically sound and can improve medical care, but are not done elsewhere because of lack of financial incentive, or institutional, cultural, or personal biases. This difficult mission requires both expertise and vision. It is easy to miss the mark.

Internet Free Speech Upheld by John S. James

On June 26 the U.S. Supreme Court ruled unconstitutional the key provisions of the "Communications Decency Act" (CDA), which would have made it a felony to place "indecent" material on a computer if a minor could obtain it. The ruling means that the Internet now has the same First Amendment free-speech protections as newspapers and books. The vote was 7-2, but even the minority would have overturned the CDA in most respects. Under the CDA, AIDS organizations publishing or distributing safer-sex information on the Internet could have been prosecuted if sexually oriented material was found offensive in any part of the country; the importance or value of the information would not have been a defense. The Supreme Court noted that there is no way to publish information on the Internet and make sure that minors do not receive it -- and that under the CDA, even parents could be prosecuted for letting their 17-year-old use a computer to obtain birth control or other information that the parents considered appropriate. (AIDS Treatment News covered this Internet censorship legislation from July 1995 to October 1996, in issues #227, 229, 236, 237, 238, 240, 249, and 256.) The case against the CDA was brought by the American Civil Liberties Union and many other organizations, on the day that President Clinton signed the legislation. The case was initially heard by a three-judge panel in Philadelphia. One litigant against the CDA, Kiyoshi Kuromiya of Critical Path AIDS Project in Philadelphia, attended that trial every day and may have been the most influential with the judges, because "unlike other litigants, I proclaimed in court that I WANTED to reach teenagers with sexually explicit safer-sex information. An estimated 25% of HIV infections occur among teenagers. I felt particularly at risk for prosecution under this law. The special three-judge panel who heard our arguments agreed that Critical Path AIDS Project would be profoundly affected by the law. They detailed their concerns in the 170-page brief and separate opinions they wrote in June of 1996. At that time an injunction was issued against enforcement of the law until the Supreme Court could rule on the constitutional issue" (which it did on June 26, 1997). Kuromiya also noted, "The Internet is going to be every bit as important as the telephone. The sweeping restrictions of the Communications Decency Act would have knocked the cornerstone out of the First Amendment guarantees of free speech as applied to the Internet for the next hundred years. We, as providers of information on AIDS treatment, safer sex, and risk management for a variety of sexual practices, can breathe a bit easier now. To criminalize the publishing of life-saving but sexually explicit information on the Internet would have been a great public-health mistake." Another litigant against the censorship law, Sister Mary Elizabeth of AEGIS (AIDS Education Global Information System (http://www.aegis.com; for information on AEGIS, see AIDS Treatment News #271), said she was "The Internet is going to be every bit as important as the telephone. The sweeping restrictions of the Communications Decency Act would have knocked the cornerstone out of the First Amendment guarantees of free speech as applied to the Internet for the next hundred years. We, as providers of information on AIDS treatment, safer sex, and risk management for a variety of sexual practices, can breathe a bit easier now. To criminalize the publishing of life-saving but sexually explicit information on the Internet would have been a great public-health mistake. Elated the Supreme Court struck it down. It was too broad and undefinable. If the CDA had been upheld, we would have had to go through every file on our system; up to half might have had to come off [AEGIS has over 350,000 documents online]. You cannot talk about AIDS in an intelligent manner without bringing sex into it. We and others could not have afforded the legal costs, and would have been facing $250,000 fines and imprisonment." For more information on the recent Supreme Court decision, see THE NEW YORK TIMES, June 27, page 1. Also see the following Web sites: American Civil Liberties Union http://www.aclu.org Citizens Internet Empowerment Coalition, http://www.ciec.org Critical Path AIDS Project (see Bulletins), http://www.critpath.org Electronic Frontier Foundation, http://www.eff.org Electronic Privacy Information Center, http://www.epic.org

AIDS CARE Newsletter

AIDS CARE is a free newsletter, published six times a year under the direction of Paul A. Volberding, M.D., director of the AIDS Program at San Francisco General Hospital. It focuses on practical suggestions for living with HIV -- especially concerning treatment, but also useful news in other areas, such as insurance, or prevention of HIV transmission. Three issues have been published so far: February, April, and June 1997. The current issue, June 1997, includes a major article on using medications effectively. The April issue included a pull-out, "Mastering Combination Therapy," with suggestions to help in taking medications on time despite pressures of work, travel, etc. Future issues will look at pain and at neuropathy, and their treatments. AIDS CARE is supported by several pharmaceutical companies, and is distributed primarily through physicians' offices. While copies are available, they are also being mailed to individuals. To be put on the mailing list, or to request the "Mastering Combination Therapy" guide, send your address to: AIDS CARE, 21 South End Ave., Suite PH-2-I, New York, NY 10280.

San Francisco, Healing Alternatives: Help Wanted, Also Directors, Volunteers

Healing Alternatives Foundation in San Francisco, a nonprofit "buyers' club" dedicated to access to complementary therapies and treatment information, is hiring an executive director. HAF also wants to expand it board of directors, and is looking for more volunteer help. Persons interested should send a cover letter and resume to: Fred Cox, Healing Alternatives Foundation, 1748 Market St., #205, San Francisco, CA 94102. Matt Sharp, the former executive director, has left Healing Alternatives to become outreach coordinator of the AIDS Clinical Trials Unit at San Francisco General Hospital.

California: AIDS Hotline Expands to Cover State, Increases Hours

On July 1 the San Francisco AIDS Foundation's English, Spanish, and Filipino AIDS information and referral hotline will begin taking calls from the entire state. Previously it served only Northern California. The hotline's new hours will be 9 a.m. to 9 p.m. weekdays, 10 a.m. to 6 p.m. on weekends. The statewide phone number is 800/367-AIDS; the local number in San Francisco is 415/863-AIDS. (The old number for the AIDS Project Los Angeles hotline, which previously served Southern California, will work for the next few weeks, and automatically transfer calls to the statewide hotline.) The TDD number for the deaf is 888/225-AIDS. Copyright 1997 by John S. James. Permission granted for noncommercial reproduction, provided that our address and phone number are included if more than short quotations are used.