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Issue #231: May 28, 1999
FASTFAX is available by fax in the 215 and 610 area codes at no cost, by mail anywhere for 20.00 per year, by calling 215-545-6868, and on the fastfax index page. Information in fastfax is drawn mostly from secondary sources; people living with HIV/AIDS should share information of interest to them with their primary care provider before making treatment choices. For more information on HIV medications and treatments, contact Kiyoshi Kuromiya of the Critical Path AIDS Project, 215-545-2212 or by email to The presence of the name or image of any individual in fastfax should not be construed as an indication of their HIV status or sexual preference unless specifically stated. Questions or comments should be directed to Editor, fastfax, 425 S. Broad St., Phila., PA 19147-1126 or by email to
In This Issue:
Studies confirm HIV persists despite HAART
3TC withdrawal may cause hepatitis flare
Mental health, AIDS drugs may be separated in SPBP
Disabled health bill approved by House committee
Stress speeds development of AIDS: study
Supreme Court helps PWAs in dental, disability cases
C-section may not be best for HIV in pregnancy
Maine rejects inmate HIV testing bill
E-magazine produces AIDS website
Internet "Living with AIDS" manual published
Phila. Foundation awards WTP $13,500
Two papers that appear in the May 27th issue of The New England Journal of Medicine confirm previous reports that HIV replication may persist in patients who are on highly active antiretroviral therapy (HAART) and have no detectable viral load.
Lingi Zhang, a researcher at the Aaron Diamond AIDS Research Center at Rockefeller University, New York, studied HIV recovered from eight patients whose blood level of the virus had remained undetectable from two to three years. But he was able to use molecular and genetic tools to find virus capable of replication in other body reservoirs, such as the lymph system.
Previous studies have shown that HIV hides in certain places in the body, including certain immune cells and organs such as the brain, testicles and eyes that are not easily penetrated by drugs. But doctors hoped that continued use of AIDS drugs would keep the virus in a dormant state and eventually kill off all traces of the infection.
Zhang suggested that it will take at least seven to 10 years of highly active antiretroviral therapy (HAART) to eliminate the reservoir, but he has doubts that is possible.
"It will be difficult to maintain treatment for such a long time, thus, we must find ways to facilitate a decrease in the size of the pool of latent virus."
In a second paper that analyzed the virus' potential to mutate, Manchar Furtado of the department of pathology at Northwestern University Medical School, Chicago, said he was still able to detect replicating virus in patients who had undetectable viral blood levels for more than 20 months. Furtado also found virus in the patients lymph system. He said that new cells were being infected almost as fast as the drugs were killing infected cells, suggesting that HIV will never completely disappear with current treatments.
"Our results suggest that this reservoir represents a serious impediment to the long-term goal of eradication" of HIV, Furtado and his colleagues concluded.
"The eradication of HIV from the body is an elusive goal," agreed Dr. Franco Lori, co-director of the Research Institute for Genetic and Human Therapy (RIGHT) at Georgetown University, Washington, DC.
Lori, a co-author of a letter in the journal, describes the "Berlin patient", a man who maintains very low levels of HIV, despite abandoning treatment.
"The papers in the journal pretty much confirm that eradication is becoming more and more an elusive goal. We know the virus has quiescent -- sleeping cells -- and sometimes these cells wake up and produce more virus. These cells stay around for a long, long time," Lori said.
Julianna Lisziewicz, co-director of RIGHT in Pavia, Italy, suggested a series of unique events may have allowed the Berlin patient to ward off the virus.
"He was treated very early in his infection, he went on and off treatment creating an intermittent treatment protocol, and he used the anticancer drug hydroxyurea in the treatment," Lisziewicz said. All three elements, she said, may have resulted in his ability to maintain health even though viable virus can still be found in his body.
Lori suggested that by stimulating an intact immune system early in HIV infection, this patient's body has learned to keep the virus in check -- much the way most people's immune systems keep herpes and other viruses in the body at bay.
Lori said he and other investigators are trying to replicate the Berlin patient protocol, working first with monkeys and a few human subjects. He cautioned both doctors and patients that the intermittent therapy is still just a theory and could be dangerous if attempted without further studies.
Despite the authors' suggestions that AIDS eradication may not be possible, Dr. Roger Pomerantz of the Jefferson Medical College of Thomas Jefferson University, Philadelphia, said scientists should not abandon the idea.
"Although the goal of a therapy capable of eradicating HIV in selected patients remains difficult to achieve, a review of the history of this epidemic still suggests reasons to remain quite optimistic about the future."
Doctors must focus on stopping the remaining low levels of viral reproduction, as well as flushing out and killing dormant HIV in immune cells, he said.
The most common hiding place for HIV appears to be in CD4+ T cells. The cells function as the immune system's memory and are found throughout the body. Previous studies have shown that they may hang on to the genetic blueprint of HIV in dormant form for years, so the body will recognize the infection and mount a defense if it appears again.
However, the studies suggest that some of these latent cells may be activated from time to time and replicate the virus even during intensive drug treatment. Infected cells in the brain, eyes and testes also may be responsible for some replication, Pomerantz said.
Higher doses of AIDS drugs might halt this low-level replication altogether, Pomerantz said.
Researchers are also looking at ways to trigger the latent HIV in CD4+ T cells, luring the virus out of its hiding place so that AIDS drugs can then find it and kill it.
Still other researchers are looking at the possibility the patient's own immune system can be trained to keep the lingering infection under control.
"These findings are not unexpected," said Anthony S. Fauci, M.D., director of the National Institute of Allergy and Infectious Diseases (NIAID), which provided major support for both studies. "The data add to other recent findings indicating that it may be impossible to eradicate HIV from the body with currently approved antiretroviral therapy. What all these studies underscore is the pressing need to develop more effective, less toxic medications that can be used over the long term to suppress HIV, as well as novel strategies to then purge residual virus from the body and boost the immune system. In this regard, many important leads are being pursued by investigators in government, academia and industry."
The era of highly active antiretroviral therapy, or HAART, began about three years ago when the first protease inhibitors were incorporated into multi-drug HIV treatment regimens that included older anti-HIV drugs such as AZT. Hopes that the drugs could "cure" AIDS were raised when some patients experienced dramatic drops in the level of HIV in their plasma. More sophisticated studies, however, subsequently turned up evidence that some virus survived the therapy by hiding in certain cells and tissues.
One bright spot in this picture, says Carl Dieffenbach, Ph.D., associate director of the Basic Sciences Program in NIAID's Division of AIDS, is that the technologies developed by these investigators provide "new tools, so that if we ever have a patient in whom it appears the virus has been eradicated, we'll be able to verify that." This ability will become increasingly important, he says, as new and improved drugs shrink the latent reservoir of HIV even further. (Sources for this article include Associated Press, NIAID, Reuters, and United Press International.)
3TC withdrawal may cause hepatitis flare
People dually infected with HIV and hepatitis B virus (HBV) may experience a severe exacerbation of hepatitis after lamivudine is discontinued or lamivudine resistance emerges, according to a report in the May issue of Clinical Infectious Diseases.
The nucleoside analog lamivudine is active against both HIV and HBV, Dr. Mary Bessesen of the Veterans Affairs Medical Center in Denver, Colorado, and colleagues explain. "Unfortunately, a mutation at the YMDD locus that is shared by the two viruses confers resistance to lamivudine," they add.
In a retrospective study, Dr. Bessesen's group identified 5 coinfected patients initially treated with lamivudine who experienced a serious hepatitis B flare.
Two patients experienced a resurgence of hepatitis B after they were switched from an antiretroviral regimen that contained lamivudine to highly active antiretroviral therapy (HAART) that did not include lamivudine. In 1 case, the patient's condition improved after lamivudine was started again. The other patient developed fulminant hepatitis and died.
The 3 other cases involved patients who experienced a worsening of hepatitis B infection while on lamivudine. According Dr. Bessesen's team, this phenomenon indicates the emergence of resistance mutations.
The investigators point out that HIV infection has been associated with a diminished inflammatory response to HBV. However, immune reconstitution appears to "...shift the spectrum of disease toward an enhanced inflammatory response to hepatitis B followed by decreased viremia and seroconversion."
At this point, the factors that predict increased risk of hepatitis B exacerbation in HIV-infected patients are unknown, the authors remark. "A better understanding of the natural history of hepatitis B infection in HIV-infected persons receiving HAART is needed." (© Reuters)
Mental health, AIDS drugs may be separated in SPBP
Pennsylvania's AIDS drug assistance program, called the Special Pharmaceuticals Benefits Program (SPBP), has traditionally covered most approved AIDS medications - but it also covered Clozaril and has been available for other drugs for people with schizophrenia.
SPBP, which pays for drugs for individuals who do not have health insurance, was started in 1987 as an AIDS-only program. However, as a result of lobbying from mental health advocates and pharmaceutical companies, the schizophrenia drugs were added later.
This has caused some concern among both AIDS and mental health advocates, who fear that combining both illnesses in the same program might reduce funding for one or the other, and complicate budget projections.
However, Bruce Flannery, executive director of the Pennsylvania Coalition of AIDS Service Organizations, says that might change in next year's state budget.
"Last minute, 'behind the scenes' lobbying on behalf of a major manufacturer of mental health pharmaceuticals achieved the impossible," he said in a statement to PCASO members last month. SPBP, previously 'shared' with Clozaril and open to addition of other mental health drugs for the treatment of schizophrenia, was cut into two separate budget lines--one for HIV drugs and one for the MH side."
Flannery said that "the 'new' HIV line was funded at the level proposed by the Governor in February ( a $1.7 million increase over current fiscal year, bringing the state generated total to $9.365 million). Based on Federal and state contributions, as well as the pharmacoeconomic model used to project expenses for the program, this will maintain the program fiscally should growth in the SPBP population not grow in excess 10%."
Flannery said that the new mental health line received the $3.2 million projected expenses for Clozaril, plus an additional, new $2.2 million, paving the way for additional drugs to be added to the mental health formulary.
"It is possible that this new money was initially intended for the HIV side," Flannery said. "Especially as it follows a focused, data driven effort from PCASO and pharmaceutical interests to add an additional $2 million for HIV meds enabling SPBP to grow by 14-17%."
Flannery called the budget split, which has traditionally been opposed by the Ridge Administration, "is good news for SPBP enrolled consumers, as it prevents the possibility of new MH drugs from competing with HIV drugs for increasingly limited dollars."
Disabled health bill approved by House committee
The U.S. House Commerce Committee has unanimously approved a bill that would allow people with disabilities to keep their government-funded health coverage even if they get a job.
The Work Incentives Improvement Act, backed by both parties, President Clinton and disability advocates, would extend Medicare coverage for working disabled people -- including those with HIV, AIDS, multiple sclerosis and other disabilities -- to 10 years from four years. It would permit states to allow people with disabilities to buy Medicaid coverage. The measure, which would cost about $800 million over five years, also provides for rehabilitation, job training and placement services.
"This empowers people," said Rep. Rick Lazio (R., N.Y.), who proposed the bill. "This is sweeping away barriers."
The barrier: Currently, disabled Americans who earn more than $500 a month lose their Medicare or Medicaid coverage. Many who can work opt not to take a job to preserve their heath coverage, the bill's supporters say.
"The committee has taken an important step toward removing significant barriers to work for one of our nation's most significant untapped resources -- millions of people with disabilities," Mr. Clinton said.
The bill must pass the House Ways and Means Committee before going to the full House. Mr. Lazio said that he hopes the measure will reach the House floor by year's end. Some differences remain, primarily over eligibility standards and costs. But Mr. Lazio said he's confident those issues can be resolved. Panel members are pushing to get it to the floor before Memorial Day. It is expected to pass with overwhelming support. (© Wall Street Journal)
Stress speeds development of AIDS: study
In a 5 and a half-year study of HIV-infected men, researchers have found that the men's passage to AIDS status was greatly accelerated by stressful events and by low levels of social support.
The probability of progressing to AIDS during the 5.5-year period was two to three times higher for HIV-infected men with more than average stress or with less than average support than for those below the median on stress and above the median on social support, the study published in the June issue of Psychosomatic Medicine reports.
"We showed that for every increase in cumulative average stressful life events -- equivalent to one severe stressor or two moderate stressors -- the risk of AIDS was doubled," said Jane Leserman, Ph.D., of the University of North Carolina School of Medicine, who headed the group of eight scientists conducting the study.
Leserman said that the finding with regard to the cumulative effects of stressful life events "is perhaps among the most compelling evidence to date linking psychosocial variables with HIV disease progression."
They started with 82 asymptomatic HIV-infected gay men and tested the participants every six months for disease status (AIDS was determined by CD-4 lymphocyte count below 200 and/or having an AIDS indicator condition), depression, stressful life events, and social support.
Thirty-three percent of the men progressed to AIDS, in an average time of 2.8 years. Eight men died of HIV-related causes.
Major depressive episodes were not significantly related to AIDS progression in the study itself, and few men were depressed at testing times. But there was a trend for men who developed AIDS to be twice as likely to have had one or more major depressions before the onset of AIDS than those who did not develop AIDS.
She added, "Now we need to determine whether interventions that have been shown to reduce distress and improve social support can alter the course of HIV infection."
The study was supported by grants from the National Institute of Mental Health and the National Institutes of Health. (Center for the Advancement of Health)
Supreme Court helps PWAs in dental, disability cases
The Supreme Court has rejected the appeal of a Maine dentist successfully sued after he refused to treat in his office a woman infected with the virus that causes AIDS.
The justices, without comment, turned away Randon Bragdon's contention that filling a cavity in Sidney Abbott's tooth at his office would have posed a "direct threat" to his health and safety.
Lower courts had rejected that claim when they ruled for Abbott without even holding a trial on her claims of discrimination.
Bragdon had urged the nation's highest court to use the case to clarify when disabled people can be treated differently under a federal anti-bias law, the Americans with Disabilities Act.
The ADA protects the disabled against discrimination in jobs, housing and public accommodations.
The same Maine dispute was the subject of a key Supreme Court decision just last June, when the justices said people infected with HIV can sue under that 1990 law.
That decision was the court's first ever involving the human immunodeficiency virus that causes acquired immune deficiency syndrome. It was hailed by gay rights activists.
In returning the Maine case to a federal appeals court, the justices said then that a health care provider's actions should be judged according to "the objective reasonableness of the views of health care professionals without deferring to their individual judgments."
Public health authorities say there is no documented case of a dentist contracting the AIDS virus from a patient. But Bragdon contended he should be allowed to use his own judgment on how to safely treat such patients. He had offered to fill Abbott's cavity at a hospital near his office, but the procedure would have cost more there.
When the 1st U.S. Circuit Court of Appeals restudied the case, it ruled in December that Abbott's legal victory in the discrimination case should stand and that no trial was necessary.
She had won a judgment saying Bragdon should stop discriminating, but received no monetary award.
The appeals court portrayed Bragdon's offered evidence of health risks as "too speculative or too tangential, or in some instances both, to create a genuine issue of material fact."
In the appeal acted on by the Supreme Court, Bragdon said the 1st Circuit court's ruling "encourages health care workers to practice below-minimum safety standards."
"Disability" standard clarified
In another case, the Court found that individuals who are deemed disabled by the Social Security Administration can still be protected by the ADA if they go back to work while still receiving disability benefits.
Some lower courts have ruled that because someone who has applied for or received Social Security disability benefits is, by definition, "unfit for employment," such a person should be barred from suing for disability discrimination, or at least face special judicial hurdles in pursuing a discrimination lawsuit.
However, in a unanimous opinion, the Supreme Court ruled that these provisions "do not inherently conflict" and "can comfortably exist side by side." The Court said that the Social Security determination of disability is necessarily broad, and does not have to be "fine-tuned" to determine whether or not a disabled worker could find work if the employer made special accommodations.
The case before the Court involved a woman who applied for disability benefits from Social Security while she was suing her employer for refusing to make the "reasonable accommodations" required under the Americans for Disabilities Act. The lower court had said that because the woman had applied for, and received, Social Security disability benefits, that had created a presumption that she could not work and thus could not sue for discrimination under the ADA.
C-section may not be best for HIV in pregnancy
A recent study suggested that HIV-infected pregnant women are less likely to transmit the virus to their infants if they deliver via a cesarean section, but this option should be used with restraint until more data are available, according to Alabama physicians.
The study did not include women on combination antiretroviral drugs and therefore the findings do not apply to most pregnant HIV-infected women in the US, Dr. Robert Goldenberg, a co-author of the report, told Reuters Health.
And a cesarean section, which is major abdominal surgery, may pose a risk to the mother's weakened immune system, according to the report in the May 26th issue of The Journal of the American Medical Association. Although data on cesarean-related problems in such women are limited, two recent reports found a twofold increase in complications and infections in HIV-infected women who underwent cesarean section.
HIV-infected pregnant women may be emotionally vulnerable and "may be willing to take on almost any risk to better, even in the slightest way, their odds against perinatal HIV transmission," write Goldenberg and colleagues from the University of Alabama in Birmingham..
Based on current data, HIV-infected women who are not on antiretroviral drugs and get treatment late in their pregnancy may be the best candidates for cesarean section. A short-course of AZT may provide an alternative treatment for these women, according to the report.
"Adoption of prophylactic cesarean delivery as a matter of public health policy now may expose many HIV-infected women to the cumulative morbidity and mortality of a procedure for which benefit has been established only for a limited few," they write.
The researchers want to help prevent "a stampede to a medical practice that we don't think in the long-run will be appropriate in the US," said Goldenberg. "And how this applies to developing countries is not at all clear," Goldenberg added. He believes it would be a mistake for developing countries to base treatment guidelines on the results of a single analysis. (Reuters)
Maine rejects inmate HIV testing bill
Just because the state has a "captive audience'' of inmates in jails and prison is no reason to force compulsory HIV testing there, according to Maine State Sen. Jill M. Goldthwait.
The Bar Harbor legislator, a nurse, said hospitals do not require the procedure and neither should prisons.
The Maine Senate agreed, and defeated the proposal by a vote of 21-13. The bill will now return to the House where it was passed 81-65.
There is "nothing broken'' in the state's prison system, said Sen. Susan W. Longley, D-Liberty, who serves as chairwoman of the Legislature's Judiciary Committee. In committee hearings, there was no public support for the bill, even from prison guards, she said. Several organizations spoke against the bill and the committee voted against the concept 9-4.
The bill could cost anywhere from $350,000 to $500,000, according to Longley.
Compulsory HIV testing would treat inmates like "government property,'' according to Sen. John W. Benoit, R-Rangeley. There has not been a single instance in the nation of a guard or jail employee contracting HIV from an inmate said Benoit, a former judge. The concept is not recommended by the National Center for Disease Control because it is not based on any risk factors and the idea could create a false sense of security, Benoit said.
State and county jails now offer voluntary HIV testing accompanied by counseling, Benoit said. "Inmates are not being neglected. There is nothing broken in the system,'' he said.
"This is a solution to a problem that does not exist,'' said Sen. Sharon Anglin Treat, D-Gardiner. She said compulsory testing is not recommended by the state Bureau of Health or federal health agencies. (Bangor News)
E-magazine produces AIDS website
Adam Stoltman and Alan Dorow, publishers of an online magazine called "Journal E," have announced a new project in collaboration with The New York Times called "Looking for Light," dedicated to people living with HIV/AIDS.
"Looking for the Light" consists of five stories about different facets of the AIDS epidemic. The stories are all the work of photographer Scott Thode, who has been documenting the AIDS crisis for the last fifteen years. The presentation uses the latest streaming media techniques to enhance the presentation and highlight the personal narratives of each story.
Also included on the site are a time line of AIDS-related events, links to AIDS resources on the web and a "Wall of Names" on which visitors can post comments about some of the individuals portrayed on the site. Viewers are also invited to respond to the stories through the extensive forums which are interwoven into the site. "Looking for the Light" can be viewed at: http://www.journale.com/aidsdecade/index.html
The New York Times on the Web is presenting a companion piece consisting of one of the five "Looking for the Light" essays. They include an article about the history of the epidemic and a time line consisting of every article about AIDS which has appeared in the paper from 1981 to 1999.
Internet "Living with AIDS" manual published
Living Positive, a 100 page guide to living with HIV disease and AIDS, has been published online by the Canadian group, the British Columbia Persons With AIDS Society. The publication covers a wide range of issues from treatment information to spirituality.
"There is a wealth of wisdom in these pages," said an announcement issued by the group. "People living with HIV disease, and professionals with expert knowledge, have shared their experiences so that you can make the best decisions about your physical and emotional health. The publication includes first hand accounts of how people are dealing with this disease in their lives.
The manual can be found at http://www.bcpwa.org/PLM/toc.htm.
Phila. Foundation awards WTP $13,500
The Philadelphia Foundation has awarded We The People $13,500 from several of its family funds to support general operating expenses of the organization, the only PWA coalition in the Philadelphia area.
The Foundation's award was drawn from the Cascaden, McCahan, and Iucker Funds, which are managed by the Foundation.
"We are honored to again be able to count on the Philadelphia Foundation for coming to the aid of our organization and its members," said Rob Capone, WTP executive director.
The Philadelphia Foundation has provided financial support to We The People and several of its programs for low-income people with AIDS since 1991.