Alive & Kicking's fastfax

Researchers released fresh information at the Vancouver AIDS conference about new cocktail approaches to treating AIDS using the great new hope of drug companies -- protease inhibitors.

Abbott Laboratories Inc said a triple combination of its Norvir and two other drugs had kept the AIDS virus at bay for 60 weeks in a clinical trial.

Abbott said 17 patients in France with advanced, previously untreated HIV infection were given Norvir, Glaxo Wellcome's AZT and Roche's Hivid.

After 60 weeks on the therapy, the count of the patients' disease-fighting CD4 cells rose to a mean of 337 from a mean of 155 cells, the company said in a statement.

Levels of the virus in the blood were cut by about 99 percent after 60 weeks of the study, Abbott said.

In a separate session, William Cameron of the University of Ottawa updated information on a study involving 1,000 patients who were given Abbott's Norvir (ritonavir) or a placebo while taking other standard combination therapy.

Those given Norvir showed a "brisk, dramatic drop" in virus levels within the first two weeks and a large rise in their CD4 cell counts, he said. Giving Norvir with other therapies prolonged survival over nine months, he added.

Roy Steigbigel of the State University of New York told the conference that using Merck's Crixivan (indinavir), another protease inhibitor, kept viral levels down and CD4 counts up even when used alone, without other drugs.

Although nearly all the 70 patients in the study had taken AIDS drugs before, mostly AZT, most stopped taking them for the 24 weeks of the study.

Forty percent of all the volunteers and half those given the highest doses showed no evidence of the virus in their blood, while CD4 counts increased by 50 percent in almost all.

Joseph Gathe of the Montrose Clinic in Houston reported on a trial using Agouron's Viracept (nelfinavir) either with or without stavudine, which is Bristol-Myers Squibb's nucleoside reverse transcriptase inhibitor.

"The combination of Viracept and stavudine (Zerit) was at least two to three fold more effective in reducing viral load than Viracept monotherapy," he told the conference.

Protease inhibitors block an enzyme crucial to the multiplication of HIV. Tests so far have shown that when taken in cocktails including AZT, protease inhibitors have reduced the virus in the blood to undetectable levels.

No one yet knows how effective these inhibitors will be over the longer term.

But some researchers reported problems with the new drugs. High doses of Norvir produced serious nausea and diarrhoea in volunteers, Charles Hicks of the University Medical center in Durham, North Carolina, said. This caused many patients to drop out of a trial.

But he said Norvir cut virus levels and the side-effects went away after about two weeks.

Roche researcher: saquinavir safe, active in 3TC/AZT combination

Patients taking saquinavir will not be resistant to other protease inhibitors, clinical data suggests.

In vitro studies have shown that when HIV develops resistance to saquinavir (Invirase) it also becomes resistant to other protease inhibitors.

But clinical studies show a different situation in patients receiving the drug, according to Noel A. Roberts of Roche, the drug's manufacturer.

"Eighty-five percent of patients treated with saquinavir for one year remain sensitive to other protease inhibitors," Roberts said. "In more appropriate, more significant combinations we would expect saquinavir resistance incidence to decline even further."

However, an expert in HIV resistance to protease inhibitors disagreed with Roberts's assessment of the data.

"The lack of saquinavir resistance in vivo, relative to that seen in vitro, could be due to the relative suboptimal activity of the compound," said Ronald Swanson of the University of North Carolina at Chapel Hill.

Researcher Emilio Emini of Merck Research Laboratories agreed with Swanson. Merck manufactures invirase (Crixivan), another protease inhibitor.

But Roberts noted that analysis of more than 1500 protease sequences from HIV isolated from patients at baseline and during saquinavir treatment (for up to three years) revealed a pattern of resistance distinct from that seen with other protease inhibitors.

In another study, virus isolates from 16 patients treated with saquinavir for at least six months were studied for sensitivity to three other protease inhibitors: Merck's indinavir, Abbott's ritonavir, and Glaxo-Wellcome's VX-478.

There was a greater than four-fold decrease in sensitivity to indinavir in 4 of 16 (25 percent) patients, to ritonavir in 4 of 16 (25 percent) patients, and to VX-478 in 1 of 11 (9 percent) patients.

"Virus isolates from five patients [31 percent] had no mutations and no significant changes in sensitivity to any of the drugs tested," Roberts said.

"Preliminary phenotypic studies indicate that virus carried by 80 to 90 percent of patients should remain sensitive to indinavir, ritonavir, or VX-478 after one year of saquinavir treatment."

Roberts also reported preliminary data from a small clinical trial of combination therapy with saquinavir, zidovudine (AZT), and lamivudine (3TC).

Study participants had a median HIV RNA level of 4.84 log[10] copies/ml and a median CD4 count of 336 cells/(micro)L at study entry.

Results after 16 weeks of treatment showed that 11 of 30 subjects (37 percent) had a reduction in HIV RNA below the limits of detection (200 copies/ml).

No serious adverse events were reported.

"Saquinavir is really a very safe drug," Roberts said.

Research into AIDS vaccine languishes

The best hope of conquering AIDS lies in the development of a vaccine, but governments and drug companies are virtually ignoring this critical area of research, scientists said.

After more than a decade of AIDS research, no vaccine has advanced to large-scale trials in humans and researchers believe the introduction of a vaccine is at least five years away and probably longer at the current pace of study.

"It is a joke," said Donald Francis, a pioneer in AIDS virology at the U.S. Centers for Disease Control and now president of Genenvax Inc. which is working on a vaccine.

"There is only one way you are going to stop this virus and that's with a vaccine... We need to do more," he said.

Prospects for a vaccine were hotly debated at the Vancouver conference. A new global effort to promote research into an AIDS vaccine was launched at the conference with backing from the United Nations and the Rockefeller Foundation.

Every day about 8,500 people worldwide are infected with HIV. Experts say prevention efforts like safe-sex education campaigns are worthwhile but are not enough to halt the spread.

Vaccines, which produce immunity to a disease and have eradicated smallpox and made strides toward eliminating polio in recent decades, offer the best hope of a solution.

"In the long run if we are going to have a substantial impact on the (AIDS) epidemic we have to look to...vaccines," said researcher David Ho of New York's Aaron Diamond Center. "Science in this area is not progressing very rapidly. We have nothing to speak of today that could be used widely."

Researchers blame slow progress so far in AIDS vaccines on a shortage of funding and hesitancy among drug companies. They say drug companies see uncertain profit prospects and potentially large liabilities if vaccines do not work. They also cite a lack of government leadership.

Some experimental vaccines have shown promise in tests on monkeys or trials with relatively small groups of people, but governments and most big drug companies have been slow to move forward. "The need for a vaccine has never been greater, but...it doesn't seem to be a global priority," said New York AIDS activist David Gold.

In the United States, vaccine study received less than eight percent of the $1.4 billion spent by the National Institutes of Health last year on AIDS research, said Dr. Margaret Johnston, scientific director of the International AIDS Vaccine Initiative. "We think an effective vaccine is achievable but the pace is going to have to be accelerated."

Disappointment about the lack of progress in vaccines contrasts with the current general mood of optimism over breakthroughs in AIDS treatment, especially protease inhibitors, which have shown remarkable success in reducing the amount of HIV in the blood to undetectable levels.

But even if these advances ultimately lead to a cure for AIDS, the cost of such therapies at $12,000 to $16,000 a year will be out of reach for most of the world's population, particularly in the Third World. If developed, a vaccine would likely cost just a few dollars a person.

Researchers estimate about 25 experimental vaccines are being investigated. Work so far has focused almost exclusively on the strains of HIV that are prevalent in developed countries rather than those spreading rapidly in Asia and Africa where a vaccine is desperately needed.

Genenvax hopes to begin large-scale human trials next year on a vaccine called gp120 based on a genetically engineered piece of the outer surface of the HIV virus. A vaccine by Pasteur Merieux of France, a unit of Rhone-Poulenc Rorer Inc., based on the canarypox virus is among those showing promise and researchers hope it will be ready for large-scale human tests in 1998.

Other approaches include using vaccine combinations, chemically inactivated HIV, HIV genetic coding and live altered HIV.

PWAs on growth hormone gain weight without eating more

Patients with HIV-associated wasting who received daily injections of human growth hormone gained weight, particularly lean body mass, without consuming significantly more calories, according to the results of a University of California San Francisco study presented in Vancouver.

The 12 patients in the study gained an average of four pounds over a three-month period without any significant increases in intake of overall calories, protein, fat or carbohydrates, the researchers reported.

"I think all of us were a little surprised by the results. Weight gain rarely occurs without a gain in caloric intake," said Viva Tai, R.D., M.P.H., a UCSF research dietitian who presented the study results. "It's remarkable that you can gain this much body mass without eating significantly more calories."

The patients -- 11 men and one woman -- gained an average of nearly eight pounds in lean body mass but lost an average of four pounds of fat, Tai said. It appears that the growth hormone was able to tap into existing fat stores in the body to build muscle, she said.

"It may be possible that the loss in fat fuels the energy required for the synthesis and maintenance of lean body mass," she said.

The results were based on food diaries in which patients recorded everything they ate during the week before they started the study and the week before their three-month follow-up visit. Over the three-month period, the patients' daily intake increased by 194 calories from 2,647 to 2,841 average total calories per day, the researchers calculated.

Those 194 additional calories could not account for the weight gain as studies have shown that AIDS patients on growth hormone burn an average of 230 extra calories a day even while at rest, Tai said. She said the results are important because they suggest that growth hormone "may work for people who have an appetite problem and can't eat 3,000 calories a day."

Building lean body mass is particularly important as this is the tissue that enables people to function and be mobile, she said.

"I can tell you from working with these patients over three years that how they walked in and how they are living their lives now are totally different. They have a different outlook on life. They are more independent. Some of these patients have had important improvements in quality of life," she said.

Viramune shows promising results

A triple combination therapy including Viramune (nevirapine) demonstrated a sustained twelve month reduction in viral load below the limit of detection in Trial BI (Boehringer Ingelheim) 1046, which was presented at the Vancouver conference.

This presentation updated the six month data that supported the recent accelerated approval of Viramune in the United States as the first drug in the non-nucleoside reverse transcriptase inhibitor class of compounds.

Viramune has a different mechanism of action and a distinct side effect profile from other approved agents. "This study has shown that we do not have to use protease inhibitors to attain long-term suppression of the virus," said Dr. Julio Montaner of the Canadian HIV Trial Network and Program Co-Chair for the International AIDS Conference, and who presented the findings.

Trial BI 1046, an international randomized, double-blind, placebo- controlled trial, investigated Viramune in previously untreated patients. The twelve month results from this study compared the combinations of AZT, ddI and Viramune; AZT and ddI; and AZT and Viramune in 151 HIV infected adults with entry CD4 counts between 200 and 600.

"This trial showed a significant improvement in CD4 cell counts from triple over double therapy which tends to persist and is enhanced at the one year mark," said Dr. Montaner. "In addition, there was a profound and sustained effect on viral load, which was still present at one year. There is a substantial advantage of triple drug therapy to drive viral load below levels of detection."

At the end of one year, the triple drug regimen using Viramune decreased the viral load below the limit of detection in over 50% of the patients, which was significantly greater than the two double therapy regimens. At present, there are no results from controlled clinical trials evaluating the effects of Viramune with nucleoside analogues on the clinical progression of HIV-1 infection, such as the incidence of opportunistic infections or survival.

In the six month safety analysis, rash was the most important adverse event observed. Rash occurred in 28% of the patients in the triple therapy arm and in 13% of patients on AZT and ddI. Most rashes were mild and easily managed. Seven percent of Viramune patients discontinued due to rash.

The Food and Drug Administration on June 21 cleared Viramune for use in combination with nucleoside analogues for the treatment of HIV infected adults who have experienced clinical and/or immunoloic deterioration. Viramune is expected to be available in August.

Panel announces new treatment recommendations

At a press conference held just before the start of the IX International Conference on AIDS, the International AIDS Society - USA announced the publication of a consensus statement on antiretroviral therapy for HIV infection. The text of the statement appears in this week's issue of the Journal of the American Medical Association, a theme issue devoted to AIDS and HIV infection.

As many as 85% of patients treated with drug combinations that include the new protease inhibitors may achieve undetectable levels of plasma HIV, according to Dr. Charles C. J. Carpenter of Brown University, who chaired the 13-member panel. HIV disease progression appears to be halted in individuals with such low viral loads, said Dr. Carpenter. "If the suppression of virus in the plasma observed after 24 months of use of the new antiretroviral drugs can be sustained for years....[it]...may be possible for HIV infection to be transformed into a manageable chronic illness in which patients can remain stable for many years."

Levels of plasma HIV-1 RNA in individuals who are still in the early stages of HIV infection are strong predictors of outcome, according to Dr. Thomas R. O'Brien of the National Cancer Institute. In his study, "...low levels of HIV-1 RNA defined persons with a high probability of long-term AIDS-free survival." Dr. O'Brien pointed out three implications of this finding.

"First, our data support the hypothesis that an HIV-1 infected person's long-term prognosis is determined early in the course of infection...

"Second, because HIV-1 RNA levels strongly predict long-term prognosis, these measures promise to be very useful tools for evaluating new therapies and vaccines against HIV infection...

"Third, because we found no lower threshold for the relationship between HIV-1 RNA and the risk of AIDS, the goal of therapy may ultimately prove to be the reduction of circulating HIV-1 RNA to the lowest possible level."

Older age at HIV seroconversion (35 years or older) was also associated with higher plasma HIV-1 RNA levels, Dr. O'Brien continued. "After considering the effect of the higher levels, older subjects still developed AIDS more quickly than younger subjects. Our study suggests that the immunological systems of older persons may be less able to contain HIV-1 infection throughout the course of infection."

Interleukin boosts immune system, study finds

Injections of the protein interleukin-2 (IL-2) dramatically increased the numbers of immune system cells in HIV-infected patients, the National Institutes of Health has announced.

A study of 40 patients with early HIV infection showed that injections of the protein boosted CD4 cell counts, no matter how much was given. But those who took the highest doses, most frequently, showed the most improvement.

"Our data suggest that therapy with subcutaneous IL-2, in combination with anti-retroviral drugs, has the potential to halt the usual progression of HIV disease by maintaining a person's CD4 cell count in the normal range for prolonged periods of time," said Dr Richard Davey, senior investigator at the NIH's Institute of Allergy and Infectious Disease.

Davey said it was not yet clear whether this translated to "clinical benefit" -- if it made the patients healthier or feel better.

The 40 volunteers gave themselves the regular injections of the IL-2, which Davey said was also useful.

The NIH said the volunteers did not feel any more ill than those given standard AIDS drugs alone. "Now we know that increases in CD4 T-cells seen with IL-2 therapy do not come at the expense of a patient's overall quality of life," said Dr Clifford Lane, clinical director at the NIAID.

Interleukin-2 is one of a number of recently identified chemicals known as cytokines, which are used by immune system cells to communicate with each other.

HIV declines among US women

Less than two of every 1,000 young women in the United States are infected with HIV, and the numbers are falling sharply in the Northeast, where HIV is most common, new statistics show.

The figures provide more evidence that the HIV/AIDS epidemic has "stabilized" in the United States, the study's authors said. In all, 6,230 pregnant women were found to have HIV in 1994, the year for which the most recent data are available.

Women in 45 states are anonymously tested for HIV when they give birth. The results provide a snapshot of the extent of HIV infection among sexually active women, who are at highest risk.

The latest data, compiled by Dr. Susan Davis of the U.S. Centers for Disease Control and Prevention, were released at the AIDS Conference in Vancouver.

They show that HIV is most common in New York state, where six of every 1,000 women giving birth are infected. Nationally, the total is 1.5 per 1,000 women, a number that has remained stable since 1989.

However, in the Northeast, the figure has dropped from 4.1 per 1,000 in 1989 to 3.2 in 1994. In the South during the same period, it rose slightly from 1.6 to 1.9 per 1,000. The numbers remained low and stable in the West and Midwest at around half of one case for every 1,000 women.

Other new CDC data show that the number of Americans actually falling sick with AIDS has also leveled off over the past two years.

"All epidemics do stop at some point. The question is how high it will be when it plateaus," said the CDC's Dr. John Ward.

Between 1990 and 1995, 335,000 Americans developed symptoms of AIDS. The total does not include those who technically have AIDS because of low blood counts but are not actually sick.

Black and Hispanic men were at sharply higher risk than others.

He found that one of every 350 black men and one every 650 Hispanic men developed AIDS symptoms during the first half of this decade. So did one of every 1,100 black women, one of every 1,800 white men, one of every 2,500 Hispanic women and one of every 15,000 white women.

Heterosexual transmission, the fastest growing category of HIV risk, largely explains the relatively high numbers among black women. Ward said they are 17 times more likely than white women to get symptoms of AIDS from catching the virus heterosexually.

The main reason AIDS cases have leveled off is the stabilization of the disease among gay white men. Since 1990, the number of homosexually transmitted AIDS cases rose 47 percent among black men while actually declining 1 percent among white men.

However, new AIDS infections are still occurring among young gay men of all races, especially blacks. First spotted in San Francisco a few years ago, the pattern has now been documented across the United States, Europe and Canada.

"The epidemic of HIV among young gay men is not only an individual tragedy but is certainly also a major public health concern," said John de Wit, a psychologist at the University of Utrecht in the Netherlands.

The trend means that substantial numbers of gay men who came of age after the AIDS epidemic was recognized are already infected, and many more will get the virus in the near future. In some parts of the United States, as many as one in 10 gay men under the age of 25 carries the virus. "The figures are high, very high, especially if we consider that these young men have become sexually active in an era in which massive effort was exerted to increase awareness of HIV risk behaviors and to promote safer sex," de Wit said.

AMA backs mandatory testing of pregnant women

The governing body of the American Medical Association has voted to advocate mandatory HIV testing for pregnant women and newborns, acting against the recommendations of the U.S. Public Health Service and one of its own committees.

On the last day of the AMA's annual meeting in Chicago, supporters of the proposal pointed to a 1994 study showing that treating HIV-positive women during pregnancy reduced by two-thirds their risk of giving birth to HIV children.

Opponents said making HIV testing a legal requirement might discourage infected women from seeking prenatal care.

"We strongly support and recommend routine counseling but voluntary testing," said Dr. Audrey Manley, the Clinton administration's acting surgeon general and director of the Public Health Service.

Although the AMA's policies carry no legal weight, they form the basis of the group's lobbying efforts. About 40 percent of American physicians belong to the AMA, making it the nation's largest organization of doctors.

President Clinton signed a law in May providing money for voluntary testing of pregnant women, with a provision for mandatory testing if the number of women getting tested doesn't reach 95 percent or the number of newborns with HIV does not decline.

Many AIDS advocates, women's, and civil rights groups oppose mandatory HIV testing for many reasons including that it discourages people from seeking care and treatment due to fear of discrimination, undermines the relationship between a woman, her family, and her health care provider, and is an ineffective means of preventing perinatal HIV transmission.

These groups instead support the implementation of the guidelines set by the Centers for Disease Control and Prevention (CDC) recommending counseling and voluntary HIV testing for all pregnant women. "These guidelines represent a sound public health approach to effectively reducing perinatal HIV transmission, and maximize the confidential and trusting partnership that must exist between patient and physician in order to achieve this goal," according to a statement issued by the AIDS Action Council in Washington.

Research said lagging on anti-HIV gel

Advances in preventing women from passing HIV to their babies may lead to "a new generation of children born without HIV," scientists and health officials said at the Vancouver conference.

But research on simple gels or creams that women could use to protect themselves is lagging, they said.

More than four in 10 HIV-infected people are women and their numbers are rising at a faster rate than men. Of the 8,500 people who are infected each day, 1,000 are babies and children.

AZT may be effective in preventing transmission from mother to baby, and researchers said they believe AZT therapy can be refined -- and perhaps shortened to be made more affordable in poor nations -- to get the perinatal transmission rate down to about 2 percent.

"We have really made incredible advances," Dr. Yvonne Bryson of the UCLA Children's Hospital told the conference. "I am optimistic about our ability to prevent perinatal transmission and create a new generation of children born without HIV."

Dr. R.J. Simonds, a U.S. Centers for Disease Control researcher, reported that since the AZT treatment guidelines for pregnant women were introduced in the United States, infection rates have dropped to 10 percent of the children from 21 percent in 1994.

The drug therapy seems most successful in preventing transmission of HIV to the fetus, but research is under way on the best way to avoid infection during labor and delivery or during breast feeding.

U.S. Secretary of Health and Human Services Donna Shalala opened the conference with an announcement of new U.S. initiatives on AIDS prevention, programs that will help protect women and children.

"We must remember that there is only one clear road to victory, only one way to stop this disease from touching the lives of any more families, any more children. We must prevent the transmission of HIV ... ," she said.

The United States over the next four years will invest $100 million more into research into microbicides -- vaginal gels or creams containing a chemical that could kill HIV on contact, Shalala said.

It will also boost vaccine research next year in a revamped program, raising spending to $116 million at the National Institutes of Health, encouraging more collaboration with biotechnology companies and bringing in an outside scientist to lead the initiative, she said.

From a public health point of view, a new easy-to-use substance may help control numerous sexually transmitted diseases that can cause infertility and sometimes death.

Microbicides could also help control the spread of the epidemic through prostitution, which has been a devastating mode of transmission in Thailand and elsewhere. One study is under way in Cameroon, but no results are available.

A great deal of research has been done on a spermicide, nonoxynol-9. That is the key ingredient in many contraceptive creams sold in drugstores and distributed in family planning clinics.

But although it is effective against HIV in a test tube there are serious questions about how well it works in women. There is some fear that instead of protecting women against HIV, the minor local irritation that the chemical can cause may make women more vulnerable to infection.

"Clinical data regarding HIV prevention are conflicting and inconclusive," said Dr. Christopher Elias, a researcher at the Population Council, an international agency at the forefront of microbicide research.

Young gay men at increased risk for HIV

Despite the fact that gay men aged 30 years and less became sexually active in an era of increased awareness of AIDS, this population remains at substantially greater risk of HIV infection than their older counterparts, said John de Wit, PhD, University of Utrecht, The Netherlands. As a result, efforts to reduce the risk of transmission of HIV among young gay men should be specifically directed towards the unique determinants of HIV transmission in this group, de Wit said.

Studies have shown that younger age is a strong predictor of high risk sex and that young gay men in particular are likely to have difficulties in maintaining safe sexual behavior practices, de Wit said. The full extent of these observations was recognized in an analysis of data from the San Francisco Young Men's Health Study, which found an HIV seroprevalence rate of nearly 18% in young gay men between 18 and 29 years of age. In this study, HIV seroprevalence rates ranged from 4.8% in 18 to 23-year-olds to 28.9% in 27 to 29-year-olds.

Studies conducted outside the US have yielded similar findings. The Vanguard Project, a study of gay men aged 30 years and less that was recently launched in Vancouver, found an HIV seroprevalence rate of 1.3% in the study population. In The Netherlands, HIV seroprevalence rates of 4.3% and 4.5% have been documented in cohorts of young gay men.

Sexual risk taking is a primary determinant of HIV aquisition in young gay men, de Wit noted. In the San Francisco study, a significantly higher proportion of young gay men than older gay men reported high risk sexual behavior, including unprotected anal intercourse in the six months prior to the study, unprotected anal sex with casual partners, and unprotected anal sex with primary partners. Similar patterns of high risk sexual behavior among young gay men have been reported elsewhere, de Wit noted.

High risk behavior among younger people is not unique to gay men, de Wit said, and risk taking behavior among most adolescents typically reflects experimentation in response to presumed feelings of invulnerability. As a result, increasing awareness of the risks of unprotected sex among young gay men by providing factual information regarding the adverse consequences of their potentially health-threatening behaviors is an inadequate approach to risk reduction, de Wit said. What is needed, he explained, are programs designed to influence attitudes towards risk taking behaviors and the perceptions that modification of individual behavior patterns are possible. Such programs must be community-based and should include informational as well as motivational and skills training components.

Doctors unsure which AIDS drugs to use-survey

Doctors are confused about which AIDS drugs to prescribe for their patients and have to base decisions on instinct rather than hard data, a survey has found.

Only 25 percent use the highly touted protease inhibitors as first-line treatment against HIV, the survey, conducted by Gay Men's Health Crisis (GMHC), found.

The group said its findings tainted euphoria over promising results of drug combination therapy reported at the 11th International Conference on AIDS.

"As promising new antiviral combinations move from a controlled clinical research environment into the doctor's office, we have to face basic questions like whether physicians have reached any consensus on how to use them," said David Barr, GMHC's Director of Treatment Education.

Few clinical studies have been done on the effectiveness of various combinations, and those that have involved only a handful of patients, the group said.

"Many physicians are having to make decisions long before we receive definitive results from trials," said Dr. Gabriel Torres, director of the AIDS center at St. Vincent's Hospital in New York. "There has been controversy about what the initial therapy should be."

The group said its findings justified the attitude taken by many AIDS patients who say they, rather than their doctors, will decide what drugs to take and when.

"I am relatively healthy and I want to stay that way," Christopher Murray, a 28-year-old social services worker from New York, told a news conference. He had just started taking a combination including a protease inhibitor, but he was nervous about the decision.

"It's like driving a high-performance Maserati. I'm not sure I can control it."

Murray complained about the side-effects of the drugs, which he said he had not been warned about.

"Maseratis don't give you diarrhea, nausea, fatigue and headaches," he said. "I take an extra pair of underwear everywhere I go."

Such side-effects have caused many AIDS patients to rebel against drugs. They have also rejected tests.

Carlton Hogan, an AIDS clinical researcher at the University of Minnesota who is also infected with HIV, said he did not bother to take blood tests to see how much virus was there because he did not believe anyone knew how to interpret the information.

"We have this modern technology, which I don't want to knock...but we have enshrined it," he told the news conference.

Forty "leading AIDS physicians" from the United States, Canada, Germany, France, Britain and Australia responded to the survey. Sixty-seven percent of them said their first choice of AIDS therapy was a combination of Glaxo Wellcome Plc'sAZT and 3TC (Epivir).

A third used AZT plus Bristol-Myers Squibb Co.'s ddI (Videx), while 25 percent used 3TC plus Bristol's d4T (Zerit). One fourth sometimes used one of the various protease inhibitors in combination with other drugs, but only 9 percent said they always used a protease inhibitor.

Price affected what they used. Seventy-one percent in the United States said payer constraints affected their decision to prescribe, while 57 percent of those outside did.

"We don't have very much data that tells us AZT/3TC is the best treatment," Barr said. "But we've had a very successful promotional campaign from the company that makes those drugs."

Torres agreed. "It's been driven a lot by the marketing strategies that have been used," he said. "I would venture that most physicians get their information about AIDS from the media rather than from peer-reviewed journals."

Clinton asks more HOPWA funds

President Clinton has asked Congress to consider amendments to increase funding for the Housing Opportunities for People with AIDS program, which House GOP leaders want to fund at the level established after a 10% reduction was initiated last year.

Clinton said his request for an additional $25 million for HOPWA and other increases would not affect the discretionary budget totals.

In his message to Congress, the President said he had reviewed the proposals and that they are "a necessity at this time."

Baltimore cancels gonorrhea tracing

Baltimore city health officials have ended their three-decade practice of tracing the sexual partners of people with gonorrhea in order to concentrate on stopping the spread of syphilis and AIDS.

"We have had to prioritize what diseases we go after," said Peter Beilenson, city health commissioner. "Everybody has to live in this era of diminished resources."

Until now, health officers contacted gonorrhea patients to explain the need for treatment and the risk to their sexual partners. Officers then contacted the sexual partners if the patient refused to do so.

Instead, gonorrhea patients will be given a booklet with tear-off cards to give to recent sexual partners that informs them they have had sex with an infected person, lists symptoms of the disease and gives the phone numbers of clinics that offer free testing and treatment.

Although the number of gonorrhea cases has dropped considerably during the past decade, Baltimore remains one of the top four cities for the disease, along with Atlanta, St. Louis and Washington.

Syphilis cases in Baltimore, however, have surged recently. Although less common than gonorrhea, syphilis is considered more dangerous because it can be transmitted in the womb to a fetus.

Baltimore had 351 syphilis cases in 1995, an 83 percent increase over the previous year. Through the first six months of this year, 218 case were reported, including 12 cases of babies diagnosed with congenital syphilis.

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