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Issue #242: August 13, 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:
Local syphilis cases jump among gay men
Protease drugs may inhibit candidiasis
One-a-day ddI dose just as effective
Circumcision may protect against HIV infection
Steep decline in mother-child transmission in US
Army investigates discharges of HIV+ employees
US says drug dispute with S. Africa nearing resolution
Earliest US AIDS case identified
After years of decline, the proportion of syphilis cases reported in Philadelphia among men who have sex with men has risen dramatically - from less than one percent in 1995 to over 36 percent so far in 1999.
The frightening increase is linked by analysts to the growing belief among many gay men, especially those who are younger, that the risk of HIV infection has been reduced and that having unprotected sex is no longer as dangerous as it once was. The increase has also been tied to the failure of AIDS prevention efforts to effectively stem the tide of unprotected sex among low-income and minority gay men.
The city's AIDS Activities Coordinating Office says that information obtained from people seeking treatment for syphilis at city health centers indicates that some of the recent rise in syphilis infections can be traced to anonymous sexual activity in "gay acres," a section of Schuylkill River Park that is widely known as a gay cruising spot. Public sexual activity in the park has been a point of controversy in the community around the park for several decades.
AACO says that over 71 percent of those treated for syphilis this year said that they had had anonymous sex with multiple partners they met in the park. More than 60 percent of the men who contracted syphilis were also HIV-positive. Almost 63 percent of the syphilis suffers were men of color.
In response to the crisis, AACO, using funding made available by the U.S. Centers for Disease Control, is working on a public information campaign with the leading HIV prevention organizations in the gay community, including AIDS Services in Asian Communities, Colours, Philadelphia Community Health Alternatives, SafeGuards, and Unity.
Dr. Lenore Absel, who works in the city's sexually transmitted disease clinic, told Au Courant that syphilis is often overlooked by people who have it. She said that the sores, rashes and lesions which are symptoms of syphilis are sometimes thought to be routine allergies or skin rashes and thus are ignored by sufferers, who remain able to pass on the infection until they are treated for the disease.
The city's prevention plan includes what is called an "adopt a street" program, in which local business and agencies will distribute condoms and safer sex information in zip codes where the new incidence of syphilis seems to be concentrated.
Syphilis is easily identified by a blood test and easily treated with antibiotics. Symptoms may not appear for weeks or even months, and after a positive blood test, a followup visit is often required to confirm the infection. Free treatment for syphilis and other sexually transmitted diseases is available at any city health center as well as at PCHA's clinic at 1201 Chestnut Street.
Meanwhile, a study has indicated that approximately 1,000 new heterosexually transmitted cases of HIV infection that occurred in the US in 1996 are attributable to syphilis.
Sexually transmitted diseases (STD), such as syphilis, exert a "co-factor effect," increasing the probability of HIV transmission, Dr. Harrell W. Chesson of the CDC said.
Therefore, a reduction in the number of HIV infections would be one of the benefits of eliminating syphilis in the US. "Syphilis levels in the USA are currently at their lowest ever," they report in the July 30th issue of AIDS, which has led to the consideration of a national campaign to eliminate this STD.
Dr. Chesson's group used a "simplified model of HIV transmission to estimate the number of new, heterosexually acquired HIV cases in the USA that are attributable to syphilis." They also looked at the direct and indirect costs associated with these cases, along with the potential savings resulting from a successful syphilis elimination program.
The estimated 1,082 heterosexually transmitted cases of HIV infection attributable to syphilis were associated with $211 million in direct costs and $541 million in indirect costs.
Dr. Chesson's group calculated that over a 15-year period, "a syphilis elimination program could save over $833 million (discounted at 3% annually) in averted direct medical costs of syphilis-related HIV infections."
Based on these figures, they conclude that "a multi-year syphilis elimination effort costing less than $833 million would likely pay for itself." (Au Courant/Reuters/AIDS)
Protease drugs may inhibit candidiasis
Italian investigators report evidence that, along with having potent antiretroviral effects, protease inhibitors may exert a direct effect on candidiasis among HIV-infected people. Candidiasis is one of the most common and uncomfortable infections among people living with HIV disease.
A decline in the incidence of some opportunistic infections has been observed among patients receiving highly active antiretroviral therapy (HAART) that includes a protease inhibitor. This decline has been "attributed to the restoration of specific immunity," Antonio Cassone of the Istituto Superiore di Sanita in Rome and colleagues said.
However, "no specific evidence that this is the only or the predominant effect of HAART on opportunistic infections has been provided."
Therefore, Dr. Cassone's team evaluated in the effects of Crixivan and Norvir on indinavir and ritonavir on enzymes associated with candidiasis, in laboratory and animal tests.
The two protease inhibitors had a strong and dose-dependent effect on the inhibition on enzyme activity and production associated with candidiasis. The drugs "also significantly reduced Candida growth," the investigators report in the August issue of The Journal of Infectious Diseases.
In addition, Crixivan and Norvir "exerted a therapeutic effect in an experimental model of vaginal candidiasis, with an efficacy comparable to that of fluconazole."
Based on these results, Dr. Cassone's group concludes that Crixivan and Norvir "have direct anticandidal effects." The researchers say these findings may help explain the "unprecedented beneficial activity of HAART on candidiasis in persons with AIDS." (Reuters/Journal of Infectious Diseases)
One-a-day ddI dose just as effective
When used in combination with stavudine (d4T), once-daily dosing with didanosine (ddI) appears to be as effective in reducing HIV viral loads and in increasing T cell counts as is twice-daily dosing.
A research group that reports the findings suggests that the more convenient once-daily ddI dosing schedule may be better tolerated by patients.
"Didanosine (ddI) is currently approved for twice-daily dosing and must be taken on an empty stomach," according to Dr. Colin McLaren, of Bristol-Myers Squibb Pharmaceutical Research in Wallingford, Connecticut, and associates. This dosing schedule has been associated with "considerable tolerability and compliance problems for some patients."
In a randomized, double-blind, multicenter trial of 87 patients who had never before taken antiretroviral drugs, Dr. McLaren's team compared the antiretroviral effects of twice-daily ddI with those of once-daily ddI. In both groups, ddI was administered in conjunction with twice-daily d4T.
At 12-week follow-up, Dr. McLaren's group found that the mean reductions in HIV viral load were similar in the 2 treatment groups. A similar proportion of patients in both groups also achieved undetectable viral loads within a comparable time period. In addition, the antiretroviral effects of treatment were sustained in both groups at 24 weeks.
"Mean increases in CD4 cell counts were also comparable for the two groups at week 12," the clinicians report in the July 30th issue of AIDS.
"In the time since this study was conducted, dual nucleoside therapy has ceased to be our standard of care for HIV infection," they point out. However, based on these findings, Dr. McLaren's group believes that "...once-daily administration of ddI makes this [nucleoside reverse transcriptase inhibitor] a useful component of highly active antiretroviral therapy." (Reuters/AIDS)
Circumcision may protect against HIV infection
Uncircumcised men have a 4-fold greater risk of HIV infection compared with uncircumcised men, according to the findings of a prospective cohort study of male truck drivers in Kenya.
The results of an early study conducted in Nairobi indicated that uncircumcised men were at significantly increased risk for HIV-1 infection, Dr. Ludo Lavreys of the University of Washington in Seattle and colleagues report. In addition, observational studies have found that areas in Africa having a high HIV seroprevalence also have low rates of circumcision.
To further investigate this relationship, Dr. Lavreys, along with associates in Kenya and Canada, performed a prospective study with 746 HIV-1-negative male trucking company employees in Mombassa. This occupationally based cohort may be more representative of the general population than patients treated at STD clinics, they point out.
At baseline, Lavreys' group collected information on circumcision status, presence of sexually transmitted diseases (STDs), and data on the subjects' sexual behavior.
"During the course of follow-up, 43 men acquired HIV-1 antibodies, yielding an annual incidence of 3.0%," the investigators report in the August issue of The Journal of Infectious Diseases. "The annual incidences of genital ulcers and urethritis were 4.2% and 15.5%, respectively."
Results of multivariate analyses, in which they controlled for demographic and behavioral variables, Dr. Lavreys' group found that "...uncircumcised status was an independent risk factor for HIV-1 infection...and genital ulcer disease."
The majority of studies that have looked at the relationship between circumcision and STDs and HIV infection have found that circumcision has a protective effect, Dr. Lavreys' group notes. The current findings "...add substantial weight to these findings."
They therefore suggest that the feasibility of implementing circumcision as a population-based intervention to reduce the incidence of HIV-1 infection and STDs be considered, especially in areas with a high prevalence of HIV-1 infection. (Reuters/Journal of Infectious Diseases)
Steep decline in mother-child transmission in US
Since the 1994 recommendation by the US Public Health Service for voluntary prenatal HIV testing and prophylactic AZT treatment to reduce perinatal transmission, the incidence of AIDS due to perinatally acquired HIV has "declined dramatically," according to a report in the August 11th issue of the Journal of the American Medical Association.
Dr. Mary Lou Lindegren, of the Centers for Disease Control and Prevention in Atlanta, and associates conducted a nationwide analysis of the incidence of perinatal AIDS, along with analysis of contributing factors. For the years 1988 through 1996, they looked at year of diagnosis and incidence rates of AIDS in infants under the age of 1 year.
Dr. Lindegren's group found that the "number of AIDS cases increased rapidly in the 1980s, peaked in 1992, and declined 67% from 1992 (907) to 1997 (297)." These decreases in perinatal AIDS cases were seen in all regions and among all racial and ethnic groups.
"The observed incidence continued to decline more than expected through the first and second halves of 1995 (17% and 31%, respectively), and declined further in 1996," the researchers report. These recent declines in the incidence of perinatal AIDS were "substantially greater than could be accounted for by the declines in births" or by the effects of therapy in delaying AIDS.
In addition, data from HIV-reporting states indicated "rapid implementation of recommendations for voluntary prenatal HIV testing and the increasing use of zidovudine by HIV-infected mothers and infants."
"We've come a very long way in a very short period of time, where we can even talk about the possibility of elimination of perinatal transmission in some areas," Dr. Lindegren told Reuters Health. These data demonstrate an "...extremely successful public health intervention, but challenges continue."
"We still need comprehensive strategies to ensure access to prenatal care, especially among substance-abusing women." HIV testing and counseling also need to become routine so women can take advantage of these therapies.
"We have to be vigilant...in our efforts to continue this success," Dr. Lindegren added. It is also important to continue to collect HIV data to monitor this success and to target efforts to maximally reduce HIV infection. "HIV surveillance will be critical to get an accurate and timely picture of future progress."
Lindegren et al. provide additional confirmation of the "dramatic impact" of the PACTG [Pediatric AIDS Clinical Trials Group] protocol 076 trial," Dr. Lynne M. Mofenson, of the National Institute of Child Health and Human Development in Rockville, Maryland, comments. These and other "data suggest that it may now be possible to consider the virtual elimination of perinatal HIV infection in the United States."
However, Dr. Mofenson agrees that potential barriers still exist, including an increasing rate of HIV infection among women of child-bearing age, along with high rates of inadequate prenatal care among these women. And although "most clinicians agree that prenatal HIV testing should be offered, in practice, fewer actually do so," she points out.
Dr. Mofenson adds that despite the dramatic declines in perinatal AIDS seen in the US, "these advances have had little impact on perinatal infection in the developing world." Progress in this area will require a "global collaborative effort and political commitment to extend the benefits that now exist in developed countries to the developing world."
Army investigates discharges of HIV+ employees
Members of Congress and the Servicemembers Legal Defense Network are questioning Army discharges of at least nine HIV-positive personnel.
The Washington Blade reports that the current Department of Defense policy on HIV-positive servicemembers "unequivocally allows any HIV-positive person to serve in the military on active duty until his or her T-cell count drops below 200, at which time the person is funneled into the disability system."
All nine of the discharged personnel had T-cell counts above 200, and the Blade reports that it is "unclear why none of them were offered the opportunity to return to active duty" after medical examinations. While the Army maintains that the policy has not changed, and the error may simply be due to an administrative oversight, Sen. John Kerry (D-MA) and Rep. Cynthia McKinney (D-GA) have asked Secretary of Defense William Cohen to account for the medical discharges. "I still believe that this can be fixed with simple administrative action," said Kerry spokesperson Jim Jones. (Kaiser Daily HIV/AIDS Report)
US says drug dispute with S. Africa nearing resolution
U.S. Ambassador to South Africa James Joseph said the conflict over applying South Africa's law aimed at obtaining HIV/AIDS therapies more cheaply is likely to be resolved soon, according to a report in the Kaiser Daily HIV/AIDS Report.
Joseph said the "assurances that the U.S. were seeking would not prevent South Africa from importing more affordable drugs or from granting local companies the right to manufacture medicine at a lower cost." Additionally, he rejected allegations that the U.S. was bowing to pressure from pharmaceutical companies and said the U.S. was not part of the industry's legal challenge to section 15(c) of South Africa's Medicines and Related Substances Amendment Act, which allows the health minister to import drugs from third parties or compel companies to grant licenses to local manufacturers. Joseph said, "We have only asked for assurances that when South Africa does these things it will play by the international rules of the World Trade Organization to which it belongs. The U.S. wants what South Africa wants -- the extension of adequate health care to the many who, for so long, have been denied the same benefits available to a small minority."
The HIV and AIDS Treatment Action Campaign, however, said the U.S. government could not indicate how exactly Section 15(c) violates international trade rules.
The issue gained public attention after ACT UP and other groups began a campaign of protests at campaign appearances of Vice President Al Gore, who chairs the U.S. committee that deals with trade rules.
This week, the Wall Street Journal reported that Gore is trying to put the problem behind him by striking a deal with South Africa.
At the vice president's urging, according to WSJ, U.S. negotiators are easing their demands and no longer seek the repeal of a South African law that is thought to violate the patent rights of U.S. companies. Instead, they are asking South Africa merely to sign a statement promising that the new law, which has yet to take effect, won't violate intellectual property rights -- promises that the South Africans have already made orally. Negotiators are pressing to complete an agreement in time for a meeting between Gore and South African President Thabo Mbeki around Sept. 20.
In late 1997, South Africa passed a law to cut the price of drugs to treat AIDS, which is ravaging the country. But it permitted two controversial practices. One, called parallel importing, is a form of "gray market" retailing. Importers would buy drugs from the cheapest sources available, whether or not manufacturers give their approval. The other, called compulsory licensing, would let the South African government license local companies to produce cheaper versions of drugs whose patents are held by multinational firms.
"Not only are [AIDS] medicines too expensive to even contemplate in South Africa," says Ian Roberts, an adviser to South Africa's Health Ministry, "but even some medicines that treat complications are becoming unaffordable."
Not surprisingly, pharmaceutical companies find the practices abhorrent because they can slash profits, undermine relations between manufacturers and distributors and weaken patent rights. Forty drug companies sued in South Africa's courts to overturn the law, and the government has held up implementation until the case is resolved. U.S. firms enlisted the U.S. trade representative's office to press South Africa to reverse course.
The WSJ article notes that neither parallel importing nor compulsory licensing is barred by international trade agreements. Even so, under U.S. law covering unfair trade practices, the trade representative is required to muscle countries anyway to comply with U.S. wishes.
In April, the U.S. trade representative listed South Africa on a "watch list" of countries whose protection of intellectual property is suspect, a move that can discourage foreign investment. Meantime, Commerce Department, State Department and trade officials have pressed South Africa to change its law.
"The U.S. is trying to get more than it got in [international] agreements," says Gary Hufbauer a trade expert at the Institute for International Economics in Washington. "It's a little bit of bluff."
Gore was targeted, says ACT UP co-founder Eric Sawyer "because he has direct ability to impact negotiations with the South Africans."
South African and U.S. officials say that the pace of negotiations on the issue between the U.S. and South Africa "quickened considerably" after ACT UP began its protests in mid-June. A week later, Mr. Gore's political director, Donna Brazile, suggested to her old boss, Eleanor Holmes Norton, the congressional delegate for Washington, D.C., that the Congressional Black Caucus might want to write the vice president and have him spell out his views.
On June 25, a day after he received the letter, Mr. Gore responded that he supported compulsory licensing and parallel importing -- a far different position than U.S. negotiators had originally taken -- and then he added the caveat "so long as they are done in a way consistent with international agreements."
Effectively, that meant the U.S. would try to negotiate a statement affirming that South Africa would follow international norms, as South African officials had repeatedly said they would do. The U.S. dropped efforts to change South Africa's law.
Instead, the pharmaceutical companies would be left to pursue their case to invalidate the law and to try to negotiate a settlement with South Africa's new health minister.
Sawyer, of ACT UP, says he would welcome an agreement as a "partial resolution," but he still may continue the protests. He wants Mr. Gore to champion a plan to produce AIDS drugs cheaply.
"If I were the vice president, I wouldn't worry so long as there is a deal," says Ms. Norton, the congressional delegate. As for the protesters, "Nothing will satisfy them." (Kaiser Daily HIV/AIDS Report/Wall Street Journal)
Earliest US AIDS case identified
The apparent start of the HIV epidemic in the US may be pushed back a decade or more.
Clinical, immunological and genetic studies performed on tissue taken from the earliest known AIDS patient in the United States suggest that HIV existed in this country prior to the late 1970s, but in a different form," according to a statement issued by Tulane University Medical Center in New Orleans.
These findings were presented by Dr. Robert F. Garry, Professor of Microbiology and Immunology at Tulane, at the 11th International Congress of Virology in Sydney, Australia.
In 1968, a 15-year-old black male was admitted to the St. Louis City Hospital with extensive lymphedema of the genitalia and lower extremities. The patient's condition deteriorated, and after 16 months he died.
At autopsy, disseminated Kaposi's sarcoma was detected in most of the patient's soft tissue. Results of tests conducted on serum and autopsy specimens frozen since 1969 indicated that this adolescent, who had been sexually active, was infected with a virus closely related or identical to HIV.
Using polymerase chain reaction (PCR) analysis of gene sequences from these tissues, Dr. Garry's team found that the patient was infected with a subtype of HIV closely related to a different strain than that known to cause AIDS today.
Dr. Garry believes the "findings suggest that viruses related to the strain may have been more prevalent prior to the pandemic spread of the virus than current virus strains."
Tissue taken from the teenage male prostitute also challenges the theory that HIV jumped the species barrier from chimpanzees to humans. Garry says the discovery challenges the human-chimpanzee HIV link and suggests that HIV mutated slower than previously thought.
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