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Being Alive
Top Ten HIV/AIDS STories of 1992
Mark Katz, MD
January 5, 1993
Being Alive 1993 Jan 5: 1

As the total number of reported US AIDS cases approaches a quarter of a million and County cases near 20,000, the twelfth year of the epidemic gives time to reflect on the major issues and strides of 1992.

1. DEMOCRATIC ELECTION VICTORY I rank this first because the upcoming Clinton administration promises to be not just an improvement but a much-needed spark in what has sometimes felt like a losing battle. The first AIDS cases were reported just several months after Ronald Reagan took office, and the lack of response of the last two administrations has been a travesty of public health and ethics. The excitement generated by Clinton and the upcoming "AIDS czarship" has led a T-shirt company to recently market an item which states, "Due to the recent change in Administration, the light at the end of the tunnel has been turned back on." Locally, the County Board of Supervisors now has what could be aptly termed a liberal majority with the election of Gloria Molina. 2. THE PROMISE OF IMMUNOTHERAPY We have certainly not reached the end of the line for antivirals (see item 3 below), but this year saw excitement generated by vaccin e immunotherapy studies (e.g. gp120 or gp160) which are safe when administered to hundreds of volunteers and which do raise antibody levels. The ultimate issue of whether this leads to decreased progression/increased survival has, however, yet to be tackled.

The new research on autologous CD8 extraction, harvesting, and reinfusion is also fueling the hopes of many. Passive immunotherapy studies (as in Hemacare's local project) have shown to the satisfact ion of many, but not all, that this is also a viable life-prolonging treatment, and wider-ranging studies will likely occur in 1993. Also locally, Dr. Jeffrey Galpin has instituted a novel study based on immune-boosting mechanisms.

Although no immune-based therapy has yet been FDA-approved, interest in this approach surged in 1992, and the future will probably find a place for one or more of these therapies in the rational treatment of HIV.

3. COMBINATION ANTIVIRAL THERAPY I don't want to suggest that we at Being Alive were ahead of the game on this one, but the headline in the July 1989 Newsletter, in an article written by me and Dr. Michael Gottlieb, stated, "Combination Therapies Offer Best Hope..." January 1992 saw the formal publication of the AZT/ddC combination ACTG study, and the International Conference in July presented several other studies all of which gave the same message. One year ago, it would have been difficult to find local physicians widely using combination antiviral therapy. Today there are many who start patients on two drugs, and the FDA concurs that for CD4 count under 300, AZT/ddC combination is the way to go! A national AIDS expert stated at the International Conference in Amsterdam regarding combination therapy, "It's not even a question anymore of if, but rather when." (Perhaps he, too, read the July 198 9 Being Alive Newsletter!) 4. APPROVAL OF DDC June saw the FDA approval of the third antiretroviral medication, closely following ddI's approval in October of 1991. DDC may well be inferior to AZT or ddI as a single drug (the study which implied this has been refuted by some, but no further data has yet emerged), but it is better tolerated than ddI in terms of lower incidence of peripheral neuropathy or pancreatitis, and is being used increasingly in combination with AZT.

The expanded access for D4T (stavudine), with anticipated approval by the middle of 1993, will mean a fourth antiviral, and hopes rise as early studies show more prolonged CD4 rise with this addition.

5. WOMEN AND HIV It will no longer be necessary by 1993 to even rank this as an issue or a stride, since the world has rapidly accepted that this epidemic is a major one for women as well as for men. Studies released this year helped corroborate that survival with HIV disease is not really different in women than it is in men, but the formerly perceived difference may have been because women present later in the course of illness (being less likely to have access to health care).

Just in case there were any left who were in doubt, the World Health Organization released this past summer the rather sobering statistic that a majority of new HIV infections acquired worldwide in 1992 have been in women. Locally and nationally, all reports point towards increasing percentages of HIV-infected and PWAs being women.

6. THE GROWING THREAT OF TUBERCULOSIS Co-infection with HIV and TB is increasingly prevalent, and has become a major public health dilemma. TB is more difficult to diagnose in the HIV+, and there is the emergence of multiple-drug-resistant strains. Of HIV+ people who are also PPD-positive (skin test used to detect exposure to TB), approximately 10% per year convert to active tuberculosis, an infection which is not truly opportunistic, i.e. anyone can be exposed and ultimately infected.

Tuberculosis also brings into highlight Hispanics and other immigrant populations. The County recently released a report which disclosed that from October 1988 to September 1991, HIV seroprevalence in Hispanic TB patients rose from 2.9% to an alarming 17.4%.

7. EARLIER USE OF ANTIVIRAL THERAPY This spring the European-Australian Collaborative Group released its data on 994 HIV-infected persons with CD4 count 400-800. The study showed (not surprisingly to many!) a statistically significant slow- down of progression to and fewer diagnoses of AIDS in those placed on AZT 1000 mg daily and followed for almost two years. The equivalent American study will reportedly be releasing its data on the 500-800 CD4 group within the next months, and it is perhaps a matter of time before antiviral therapy will be officially recommended for those with CD4 counts higher than 500. Also, when nationally renowned AIDS experts such as Paul Volberding and Lawrence Corey say that they would use AZT on a person who just seroconverted, many listen! 8. STRIDES IN PCP TREATMENT With improvements in prophylaxis and earlier/more aggressive treatment, the incidence of PCP as a proportion of AIDS-related illnesses has been on the decline. In November, the FDA approved a new drug, atovaquone (trade name, Mepron, manufactured by Burroughs- Wellcome), known formerly as BW566C80. This is recommended as second-line therapy for PCP, i.e. for someone who has failed on or is intolerant of TMP-SMX (Bactrim or Septra). In addition, corticosteroid medication, usually prednisone, is now recommended for virtually all cases of PCP, mild-to-moderate as well. Dr Marcus Conant of San Francisco estimates that the median survival after a bout of PCP in 1981 was six months and today it is over three years! 9. MORE PROPHYLAXIS OF OPORTUNISTIC INFECTIONS The FDA will likely soon approve rifabutin as prophylaxis for MAI infection, making this the second OI to have standardized preventative treatment. Unlike TMP-SMX for PCP, however, this medication (very well tolerated by the way) may halve the incidence of MAI but does not bring it down to near zero. Nevertheless, disseminated MAI infection is possibly the leading cause of death from AIDS in Los Angeles, and thus halving the rate would be a tremendous boost to overall survival. Further strides have been made towards prophylaxis for CMV infection, toxoplasmosis and fungal infections.

10. LONG-TERM SURVIVORS Whether it be different strains, better CD8 function, more antibo dy or something else, it is medically clear now that approximately 8-9% of gay/bisexual men infected for 12 years or more have essentially normal CD4 cells (over 500) and are asymptomatic. Their CD4 cells are not in decline, and more study of these long-term "containers," as I call them, or survivors are called for and are being done. Next time you hear someone call HIV infection "invariably fatal," tell them they are wrong!

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