April 1999 Treatment Chronicles
Mutation Thwarts Cocktail | Antiviral Therapy by Intravenous Drug Users | Coordinating Alternative Therapies | Outsmarting the Virus | Viruses as Vectors | Rx for B and C | New Test for Blood Supply | STD Testing Risk | Condom Goals | Teen Substance Abuse | Churches Fight AIDS | Demographic Fatigue
Use of Antiviral Therapy by Intravenous Drug Users With HIV. Sharon B. Mannheimer and others from the Columbia University College of Physicians and Surgeons in New York City report in a letter to the editor findings that differ from a recent study by David D. Celentano and colleagues. Celentano, of the Johns Hopkins School of Hygiene and Public Health, and associates reported antiretroviral therapy (ART) use among 51 percent of HIV-infected intravenous drug users in their survey. In a separate survey, Mannheimer et al. found that 78 percent of HIV-infected IDUs were receiving ART. Possible discrepancies between the surveys could have arisen from the fact that their subjects were participating in a drug rehabilitation program including on-site HIV primary care. In another letter, Dr. Stephanie H. Michaels and colleagues from the Louisiana State University School of Medicine found results similar to Celentano et al: HIV patients with a history of substance abuse, incarceration and who are AIDS-free are unlikely to receive ART. Meanwhile, Dr. Rita Murri and others from Catholic University of Rome also note that ART use may be underestimated when compiled by self-reporting. In response, Celentano and Dr. David Vlahov state that Mannheimer's findings demonstrate the major recommendation of the original study -- that combination therapy can be effectively promoted in conjunction with other services.
Doctors Should Coordinate Use of Alternative Therapies. Throughout the United States, use of alternative therapies has increased from 33.8 percent in 1990 to 42.1 percent in 1997. According to Dr. Donald Abrams, assistant director of the AIDS Program at San Francisco General Hospital, between 40 percent and 70 percent of HIV/AIDS patients have turned to some kind of alternative or complementary medicine. Because of this, physicians should be aware of any alternative treatments their patients are taking in order to assess potential side effects with prescribed drugs and treatment outcomes. Abrams notes that "physicians need to learn how to ask their patients whether or not they're using them." Washington, D.C. physician and author Richard A. Elion notes that it is not surprising many HIV-infected individuals often seek both forms of treatment. According to Elion, alternative medicine sometimes better addresses restoration and maintenance of the immune system, while drug therapy helps suppress the viral load.
Outsmarting the Virus. Due to HIV's propensity to develop drug resistance, scientists and physicians are attempting to create methods to treat patients infected with resistant strains. While anti-HIV medication may fail in as many as half of all patients, researchers have developed a method that may increase treatment success. With resistance testing, physicians may be able to determine if patients will succeed on a regimen before they even begin taking the drugs. Two types of tests exist: genotypic and phenotypic. The genotypic test is fast and relatively cheap, but results can be difficult to interpret. The phenotypic test offers clearer results, but can take several weeks and costs about twice as much. Both tests appear to be cost-saving, however, as they can prevent patients from spending money on expensive drugs to which their HIV strain may be resistant. Recent research shows that the tests are fairly effective in helping determine if patients have a resistant strain and what drugs they are resistant to, thereby helping their physicians plot an appropriate regimen. Although there are still doubters in the medical field and insurers have not yet agreed to pay for the service, the cost-effectiveness and initial indications of the efficiency of the tests should change this.
Viruses as Vectors. Recent discoveries have helped researchers engineer HIV for possible use as a vector system. Prior to the use of lentiviruses as vectors, scientists could only infect nondividing cells ex vivo, so cells in the liver and brain would not benefit from gene therapy. In 1996, Inder Verma, of the Salk Institute for Biological Studies, first reported the use of the retrovirus as a vector system. Verma and others deleted the genes in HIV that allow it to replicate, leaving the genes that allow the virus to integrate into the host genome. The system has been used to deliver genetic material to nondividing cells in mouse and rat models without adverse immunological effects.
Rx for B and C. Researchers and physicians may be gaining ground on hepatitis B virus (HBV) and hepatitis C virus (HCV) infection. HCV infects an estimated 4 million Americans, and HBV is the most common cause of liver disease worldwide, infecting some 350 million people. More than 80 countries have begun inoculating their children against HBV, which spreads readily via sexual contact. The vaccination effort in Saudi Arabia, for example, has reduced the HBV infection rate among young children from 7 percent to 0.5 percent in eight years. However, the vaccine is expensive, and it is not useful to people who are already infected; costly drugs such as interferon are needed to fight infection. In the United States, the Food and Drug Administration approved the use of the anti-HIV drug lamivudine for use against HBV infection. Two other drugs, lobucavir and adefovir, are in clinical trials and appear to be effective against the disease. Another drug, alpha-thymosin, appears to boost T-cell response in infected individuals. Treatments for hepatitis C have been harder to develop because researchers cannot get the virus to grow in animal models or in human cell cultures. Interferon has been the main treatment for the disease, and in December the FDA approved the use of ribavirin, with interferon, for infected individuals.
New Test Developed for Blood Supply. Blood banks began using genetic fingerprinting tests for viral infections in the nation's blood supply. While the blood is already safe, the new tests promise to make the blood supply even safer, using nucleic acid testing to identify tiny amounts of viruses, including hepatitis C virus and HIV. Additionally, while older tests screen for antibodies in a donor, allowing an infected donor to occasionally slip through the system, the new tests -- which can screen for the actual viruses -- can detect viruses even before the donor's immune system recognizes the infection. The new technique is technically still experimental, but the FDA is strongly encouraging blood banks to quickly initiate nucleic acid screening. The tests will initially be used to screen for hepatitis C virus and HIV, with other pathogens to follow. Although the testing will increase costs by about $6 or $7 per unit of blood, experts believe it will prevent about 84 causes of hepatitis C transmission through blood each year.
STD Testing Can Carry Risk. Michael Adams, staff counsel for the American Civil Liberties Union AIDS Project, asserts that increased surveillance of sexually transmitted diseases does not always result in better information or improved public health. In a letter to the Washington Post, Adams cites research by the ACLU that shows some people at risk for HIV did not seek testing due to concerns over confidentiality. Adams argues that "if counting of HIV cases is necessary to learn more about the epidemic, it should be done by a means other than names so that people's confidentiality and confidence in testing will be protected." He adds that the ACLU supports the use of unique identifiers that allow for HIV tracking without the use of names.
Condom Use Goals Still Not Met. A 1996 survey of U.S. adults shows that condom use has not met levels aimed at by the Healthy People 2000 national health objective. According to John E. Anderson of the CDC and others, condom use has increased overall, but the adoption of condom use by high-risk individuals needs to be at higher levels. The researchers, who published their findings in the journal, Family Planning Perspectives, particularly noted that high-risk individuals need to increasingly use condoms with their steady partners. The objectives call for 50 percent condom use among sexually active, unmarried people by the year 2000; however, the 1996 survey indicated that 40 percent of these people use condoms. Condom use, within an ongoing relationship, was also determined to be higher among African Americans, younger people, people from urban areas, and people of lower income.
Detecting Teen Substance Abuse. The federal Substance Abuse and Mental Health Services Administration (SAMHSA) released new guidelines the week of March 1 to help adults detect substance abuse among adolescents. Changes in behavior, hospital emergency room visits for trauma injuries, psychological difficulties, changes in grade point averages, gastrointestinal disturbances and unexplained school absences were all highlighted by SAMHSA as potential indications of teen substance abuse. Statistics show that an estimated 77,000 young people under the age of 18 attended substance abuse treatment in 1996, compared to 44,000 teens in 1991. Studies indicate that teens who use alcohol and drugs are more likely to participate in risky behaviors that increase the likelihood of early pregnancy or contracting a sexually transmitted disease, including HIV. The guidelines are available at www.samhsa.gov/csat/csat.htm.
Helping Churches Fight AIDS. The director of the Arthur Ashe Institute, Ruth C. Browne, writes in a letter to the New York Times that the organization was created in part to help change perceptions by African-American clergy on HIV infection. Browne states that Ashe believed that the church should promote AIDS education. Browne quotes Ashe as saying that "in the minority community, among blacks in particular, the religious community in the aggregate admitted it was slow in reacting to the AIDS crisis." He noted that this hesitancy was partly due to fear and partially due to medical ignorance. Browne states that the church is a pivotal part of the African-American community and can help prevent the spread of HIV.
Demographic Fatigue. Some countries that have high birth rates and low death rates are experiencing so-called demographic fatigue, which results in problems with child education, job creation, and the environment. These countries also may experience a resurgence of traditional diseases, such as tuberculosis, and new diseases, such as AIDS. These problems can force a country into pre-industrial demographic conditions characterized by high birth rates and high death rates. Some African countries are already beginning to slide back to these levels. In Zimbabwe, for example, the adult HIV infection rates is 26 percent, and the nation cannot afford costly anti-HIV medication. Zimbabwe is expected to reach population stability in 2002, with Botswana, Namibia, Zambia and Swaziland also expected to follow this course.
This article was provided by AIDS Survival Project. It is a part of the publication Survival News.