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Local Studies with All HIV/AIDS Patients

September 8, 2000

Certain localities have been able to assemble cohorts that reach essentially the entire population seeking care for HIV- or AIDS-related illness. For example, since 1986 the Canadian province of British Columbia has distributed anti-HIV drugs at no cost through a centralized system under specific guidelines, making tracking and analysis relatively simple.

In order to compare the real-world results of dual-nucleoside combinations vs. three-drug regimens including either a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor, researchers at the British Columbia Centre for Excellence in HIV/AIDS studied all HIV-positive patients in the system who began anti-HIV treatment from October 1, 1994 through December 31, 1996. In a multivariate analysis (using statistical methods to adjust for a variety of differences between patients), those on two drugs were over three times as likely to die as those on three.(20)

San Francisco has an AIDS surveillance system that captures basic data for approximately 95 percent of the city's AIDS patients, and this data is particularly interesting in light of Farber's allegations. Unlike the study Farber cites, which used a complex collection of computer models and projections to estimate HIV infection rates and AIDS cases, this "active surveillance" system assembles data on actual patients from health care facilities, death certificates and other sources. An analysis of this information was published earlier this year in the American Journal of Epidemiology, with a year's worth of additional follow-up presented at the International AIDS Conference in Durban, South Africa (July 9-14, 2000).

The first report found that survival after an AIDS diagnosis improved dramatically for those diagnosed in 1995 and 1996 compared to earlier periods. Researchers then analyzed all deaths among San Franciscans diagnosed with AIDS from 1993 through 1996 for whom treatment and CD4 data was available, finding that any antiretroviral treatment, before or after an AIDS diagnosis, significantly reduced the risk of death. When protease inhibitors were included the risk of death was cut by 75 percent compared to no treatment. The analysis included deaths from all causes, so any deaths from drug toxicities were included.(21) The research team's Durban presentation extended the findings through 1997 and again found that "antiretroviral therapy, especially combined with a protease inhibitor, strongly predicts improved survival."(22)

A number of other presentations at Durban reported a similar association between HAART and reduced rates of death and illness. Dr. Gary Reiter of the River Valley HIV Clinic in Holyoke, Massachusetts presented an analysis of HIV patients seen at his clinic and another Holyoke facility from March 31, 1997 to December 31, 1999.

177 of 300 patients were on HAART, defined as any regimen that maintained HIV suppression below 25 copies. According to Reiter, baseline characteristics of HAART and non-HAART patients were similar, except that those not on therapy generally went untreated because of psychosocial instability, mental illness and/or substance abuse. 20 of 23 deaths were in the 123 non-HAART patients. None of the three HAART deaths were due to AIDS-related infections, but one was from a drug side effect: ddI-related pancreatitis.(22, 23)

Reiter, who began his career in San Francisco at the start of the AIDS epidemic, commented, "Those of us who've been involved with the epidemic since '81 know that antiretroviral therapy works. I had hundreds and hundreds of patients die in San Francisco (1981 to 1985) and then western Massachusetts (1987 to 1995) until we got effective therapy. We are coming up on four years now of no AIDS deaths in treated individuals."(24)

Even early skeptics about some of the mainstream ideas have seen the value of anti-HIV treatment. Joseph Sonnabend, M.D., who treated some of the first AIDS patients about 20 years ago and whose early articles are still quoted on some denialist Web sites, now says, "the antiviral therapies available since about 1996 can be life saving in people with more advanced disease, and HIV clearly plays a central role in this disease."

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ISSN # 1052-4207

Copyright 2000 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.

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