&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& J O H N J A M E S writes on A I D S &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& Copyright 1992 by John S. James; permission granted for non-commercial use. AIDS TREATMENT NEWS Issue #161, October 16, 1992 phone 800/TREAT-1-2, or 415/255-0588 CONTENTS: [items are separated by "*****" for this display] TB Diagnosis: New Test Gives 48-Hour Result Pneumocystis Prophylaxis: Conant Reports Co-Trimoxazole (Bactrim, Septra) Desensitization Procedure Itraconazole Approved Itraconazole for Eosinophilic Folliculitis: Interview with Marcus Conant, M. D. d4T Parallel-Track Program Begins Warning: Ultraviolet Light May Stimulate HIV Psychological Health and the Immune System HIV Treatment in Prison: Vacaville Update Vacaville Prison Seeks HIV Physician AmFAR Announces Community-Based Research Grants: Letters Due November 5 ***** TB Diagnosis: New Test Gives 48-Hour Result On October 8, Roche Biomedical Laboratories announced commercial availability of a test to detect active tuberculosis in 48 hours, compared to three to six weeks previously required for bacterial cultures. The new test uses PCR technology, in which a segment of DNA which is specific to the Mycobacterium tuberculosis organism is made to double many times in the laboratory; if any is present in the sample, the amount increases through successive doublings until it can be detected by standard methods. (Roche also produces PCR tests for HIV, human papilloma virus, Lyme disease, and other conditions.) The new test costs about $175. No test kit is provided; instead, a sputum sample is sent to the laboratory. For information or to arrange for the test, medical professionals can call Roche Biological Laboratories Center for Molecular Biology and Pathology, 800/872-5727. ***** Pneumocystis Prophylaxis: Conant Reports Co-Trimoxazole (Bactrim, Septra) Desensitization Procedure by John S. James The most effective treatment for preventing pneumocystis in persons at risk, whether or not they have already had pneumocystis, is believed to be the drug combination trimethoprim and sulfamethoxazole (co-trimoxazole, also called Bactrim, Septra, and various other brand names in different countries). There is also evidence that the same treatment provides substantial protection against toxoplasmosis. The drug is not expensive, and is taken orally. The major disadvantage of co-trimoxazole prophylaxis is that half or more of persons with HIV (compared to only about three percent of the general population) cannot tolerate the drug, due to skin rashes, fever, and other drug reactions, which in rare cases can be life-threatening. No one knows why persons with HIV are more likely to react to this and other drugs. But the consequence of the drug reactions is that many people have had to switch to less effective forms of pneumocystis prophylaxis such as aerosol pentamidine. Desensitization procedures, in which persons are started on tiny doses of a drug and then the doses are gradually increased, have long been used to overcome sensitivity to certain important drugs such as penicillin. And since 1986, there have been several reports in the literature of desensitizing persons with HIV to co-trimoxazole. But until recently only a few patients had been treated, and the desensitization procedure usually was done in a hospital, so the method did not come into widespread use. At the Eighth International Conference on AIDS (in Amsterdam, July 19-24 1992), Marcus Conant, M. D., a leading AIDS specialist in San Francisco, presented a poster on outpatient desensitization procedures [Conant M. and Dybul M., Trimethoprim/Sulfamethoxazole Hypersensitivity and Desensitization in HIV Disease, abstract # 3291]. Since then Dr. Conant and his associates have revised the procedure (the published abstract had to be submitted in early March), and prepared detailed instructions for physicians, patients, and pharmacists, so that co-trimoxazole desensitization can be used more widely. Instead of reproducing the instructions here, we will outline what the procedure involves, and provide a phone number so that physicians can get copies of the information packet. The current procedure was tested in 25 persons with HIV; their average T-helper count was 87. All had had co-trimoxazole reactions, but those who had had very serious reactions (such as Stevens-Johnson syndrome) were excluded. The desensitization procedure lasted 8 days. On the first day, patients used a one-to-one-million dilution, prepared by a pharmacist, of a commercially available liquid form of co- trimoxazole. Four escalating doses were taken at six-hour intervals from an oral syringe in which the drug was supplied; at the end of the day, the syringe and any remaining drug in it were discarded. Each day the concentration of the solution was increased ten fold. The patient followed an identical procedure of each of the first seven days (making sure to use the right syringe for each day); on day eight, the procedure was different, ending with a double-strength co-trimoxazole tablet, which patients then continued to take every day. This procedure was successful in 21 of the 25 patients. They have now remained desensitized for an average of over three months. But side effects during the desensitization could be severe; 12 of the 25 patients required treatment with prednisone to suppress the reaction to the drug. Another physician in Dallas used the same procedure and desensitized 24 of 25 patients; however, the one failure developed Stevens-Johnson syndrome, and later died due to complications. Many other safety precautions were taken. Each patient took the first dose in the physician's office and remained there for an hour. Each needed a friend or other person as home monitor, to watch them after each dose and get help in case of anaphylaxis (a rapid and extreme allergic reaction). Patients were told to drink 3 liters of water per day, use a #15 sunscreen if exposed to the sun, and not interrupt the therapy even for a day or two (unless treatment must be discontinued), because allergic reactions can occur when treatment is restarted. Frequent physician calls to patients and office visits were important to a successful outcome. This list of precautions is not complete. Obviously the desensitization procedure involves significant risks and must be done under a physician's supervision. For More Information Dr. Conant's office has prepared an information packet which includes an explanation and protocol for physicians, written instructions for patients, and instructions for pharmacists on how to prepare the drug dilutions. To obtain a copy, health-care providers should call Christopher King, 415/661-2614. [Note: On October 14 researchers at Kaiser Permanente Medical Center in Los Angeles described the successful use of a different co-trimoxazole desensitization procedure, which is completed in a single day in a physician's office. AIDS TREATMENT NEWS plans to publish a report on this method in a future issue.] ***** Itraconazole Approved On September 11, the U. S. Food and Drug Administration approved itraconazole (brand name Sporanox), an antifungal. It is officially indicated for treatment of histoplasmosis and blastomycosis, but physicians can prescribe it for other conditions. Other AIDS-related uses have included aspergillosis (a rare but life-threatening fungal infection) and eosinophilic folliculitis (a skin condition which causes intense itching -- see article below). Before approval, the drug was obtained abroad or from buyers' clubs. Itraconazole must not be combined with terfenadine (Seldane); other warnings are included in the package insert, which contains prescribing information for physicians. Itraconazole will be expensive in the U. S., but somewhat less expensive than fluconazole. ***** Itraconazole for Eosinophilic Folliculitis: Interview with Marcus Conant, M. D. by John S. James A skin condition which can cause intense itching, eosinophilic folliculitis, may respond to itraconazole, a new antifungal. Marcus Conant, M. D., has seen good results in his patients, and is about to start a study in San Francisco to obtain authoritative information. The potential treatment was first noticed by physicians in Europe. Itraconazole was only recently approved in the U. S. ; before then, U. S. patients obtained the drug abroad or from buyers' clubs. We asked Dr. Conant to describe his use of the drug, and the San Francisco trial he is planning with the developer, Janssen Pharmaceutica. MC: "Eosinophilic folliculitis is an unexplained inflammatory infiltrate around the hair follicles in the skin, which instead of just having nutrophils and lymphocytes at the follicle, also has large numbers of eosinophils [a kind of immune-system cell], suggesting that this condition may be an allergic reaction to some organism in the skin. A number of researchers have looked for an organism which causes the condition, but nothing has been found consistently. "In the past, what has been used to treat eosinophilic folliculitis has been low doses of ultraviolet light, just enough to cause a tan. Nobody knows why this works. High-dose cortisone can also relieve the condition; but cortisone is immunosuppressive, so it should be avoided if possible. Various topical medicines have also been tried, none with much benefit. "Last year physicians in Scotland reported that when patients were treated with itraconazole [for other purposes], they had seen the itching stop. I treated a few patients and found that was true; I also tried fluconazole, a similar drug, and ketoconazole for eosinophilic folliculitis, and they have not been beneficial. We have now applied for investigational new drug approval to test itraconazole in a series of patients, to see if this observation can be confirmed scientifically. "If this drug does in fact work, then either it is effective against some organism which is not susceptible to the other drugs, or it might be working through some other mechanism in the hair follicle." JJ: Itraconazole has been reported to concentrate in the skin. MC: "That's right. One way we expect that this drug might be used, now that it is approved, is to treat someone with a fungus in their nail for a month or so, then stop the drug since it may stay there and continue to work. If this theory works, you might only have to treat the patient for a month every three or four months. The advantage is that you would not constantly expose the liver to the drug. "Itraconazole is also important because it has very good activity against aspergillosis, a rare fungal infection. Fluconazole and ketoconazole have some activity in this disease, but less. Now that the drug is approved, physicians will learn quickly what conditions it may be effective for where fluconazole and ketoconazole have been less useful. "Itraconazole, like ketoconazole, requires stomach acidity to be absorbed; that is not true of fluconazole. And many patients with less than 100 T-helper cells do not make enough acid in the stomach. In our study, which will start next month, we will measure itraconazole after oral administration with and without a diet Coke given at the same time. Theoretically that drink should put enough acid in the stomach so that the drug will be absorbed. But we have to demonstrate that this really will work. "If people have eosinophilic folliculitis and would like to work with us in the trial to show whether itraconazole is effective, they should call Christopher King, 415/661-2614. He will be administering this study." JJ: For people who are not in the area or do not want to join the trial, how have you been treating patients in the past? MC: "The dose used in Europe was 300 mg per day of itraconazole for about a month. "Patients should have their liver functions followed. Liver toxicity has been reported less with itraconazole than with ketoconazole, but it can occur." ***** d4T Parallel-Track Program Begins The parallel track program for the anti-HIV treatment d4T (described in AIDS TREATMENT NEWS #159, September 18) obtained FDA approval on October 5. Physicians can call 800/842-8036 for information and instructions for enrolling patients. This program is for patients who have T-helper counts under 300 and have failed both AZT and ddI -- either because they could not tolerate those drugs, or because their condition continued to worsen despite treatment with each. The drug's sponsor is Bristol-Myers, which also sponsored the expanded-access program for ddI before that drug was approved. The d4T program has been designed to involve less paperwork for physicians than the ddI program, to be more accessible to patients receiving their care at public clinics, and to give somewhat more leeway to physicians who believe that their patient should be in the program. Incidentally, the way that drug "failure" (for AZT and ddI) is defined makes it easy for persons with T-helper counts under 50, who have been treated with those drugs, to qualify for the d4T program. Comment d4T might be less toxic than AZT or ddI, and at least as effective in raising T-helper counts. However, much less is known about it than about the approved drugs. Meanwhile, the reports we are hearing about ddI continue to be good; persons who are not doing well on AZT and have no contraindications for ddI should consider switching. More information about ddI should be available in the next few months. The new parallel-track program for d4T seems to be a good as we can hope for at this time. However, we believe a better policy would be to allow urgently-needed drugs which are ready for parallel track to be marketed instead, under conditional approval, and reimbursed by public or private insurance like other approved drugs. Such a system would (1) give more control of medical decisions to physicians and patients, (2) allow earlier access to drugs like peptide T which do not have a major developer able to afford parallel track, (3) be at least as equitable across social classes as "free" distribution which requires physician time and laboratory tests commonly paid for out of the patient's pocket -- or the physician's; (4) allow faster learning about new treatments under conditions of practical use, and (5) permit small companies to bring out the most important new advances (such as tat inhibitors) when big companies are not aggressive or not effective in doing so. We do not think this approach would endanger the public, because it would only apply to drugs already considered safe enough for release to thousands of patients under parallel track. And, like parallel track, it would only apply for serious and life-threatening conditions when there was a compelling need for the drug. But politics is "the art of the possible." Decades of struggle between liberal (consumer protectionist) and conservative (pro business) positions, neither of which serves the public interests very well, hardened into rigid battle lines with both sides reluctant to give up ground. And the current inefficiencies favor big business, which finances most of the leading researchers, who are accepted uncritically as authorities by the press, politicians, and policy experts, who seldom have the scientific background for an independent evaluation. Problems persist because the system does not generate much constituency for doing things better. Until more of the public gets involved in AIDS and related activism, we will be stuck with second best. ***** Warning: Ultraviolet Light May Stimulate HIV by John S. James A recent article in Science (August 28, 1992, pages 1211- 1212) reviewed current evidence from test-tube and animal studies that ultraviolet light -- including sunlight, tanning studios, and medical treatment for certain skin conditions -- might help stimulate activity by HIV which otherwise was latent in infected cells. While there is no conclusive proof of harm at this time, study after study has found evidence of HIV activation after UV exposure in laboratory cells or in genetically altered mice.(1,2,3,4) (AIDS TREATMENT NEWS published an earlier warning about ultraviolet light in issue #58, June 3, 1988, after a laboratory study(4) found that ultraviolet light could increase the activity of HIV genes as much as 150 times.) No comparable human study has been done. But one study of herpes(5) (not HIV) found that 71 percent of 38 patients developed a recurrence of lip herpes when exposed to ultraviolet light with a placebo sunscreen; by contrast, with the same ultraviolet exposure with real sunscreen, none of 35 patients developed the recurrence. An early epidemiological study of seasonality of AIDS(6) by researchers at the U. S. Centers for Disease Control might be relevant. It found a 12 percent difference in AIDS diagnosis with the peak in the summer (when there is most exposure to ultraviolet in sunlight) and trough in the winter. Pneumocystis and Kaposi's sarcoma also showed a peak in the summer and trough in the winter; CMV as a subsequent diagnosis, however, had a peak in the spring and trough in the fall. But the paper concluded that "there is no important seasonality in the onset of AIDS" (apparently because the 12 percent difference was not considered large enough, and ultraviolet light was not a concern at that time), and the study has been remembered as a negative result. One study in England(7) found that people with HIV were strikingly unaware of the risk; they were almost three times as likely to use a sunbed regularly than HIV-negative controls. The researchers also found that two thirds of the HIV-positive group believed that a suntan would improve their health. They noted that "those with HIV infection must be made aware that there is a potential for further immunosuppression and viral activation from ultraviolet radiation and they should be advised to avoid undue recreational exposure." Comment Enough is known now to suggest that the risk of ultraviolet light to persons with HIV may be serious; it is important to warn the community, even while we wait for definitive information. Nobody knows why HIV disease progresses much faster in some people than in others. If ultraviolet light, among other factors, contributes to faster disease progression, it probably would have escaped notice. When ultraviolet is used for medical treatment, the risk should be considered in balancing the benefits and drawbacks of therapy. The bigger concern is sun exposure and tanning studios (which are often targeting the gay community as customers). Dermatologists have long warned the public against unnecessary ultraviolet exposure, to avoid damage to the skin. Persons with HIV should know that they may be at greater risk. References 1. Vogel J, Cepeda M, Tschachler E, Napolitano LA, Jay G. UV activation of human immunodeficiency virus gene expression in transgenic mice. JOURNAL OF VIROLOGY. January 1992; volume 66, number 1, pages 1-5. 2. Morrey JD, Bourn SM, Bunch TD, and others. In vivo activation of human immunodeficiency virus type 1 long terminal repeat by UV type A (UV-A) light plus psoralen and UV-B light in the skin of transgenic mice. JOURNAL OF VIROLOGY. September 1991; volume 65, number 9, pages 5045-5051. 3. Stein B, Kramer M, Rahmsdorf HJ, Ponta H, Herrlich P. UV- induced transcription from the human immunodeficiency virus type 1 (HIV-1) long terminal repeat and UV-induced secretion of an extracellular factor that induces HIV-1 transcription in nonirradiated cells. JOURNAL OF VIROLOGY. November 1989; volume 63, number 11, pages 4540-4544. 4. Valerie K, Delers A, Bruck C, and others. Activation of human immunodeficiency virus type 1 by DNA damage in human cells. NATURE. May 5, 1988; volume 333, pages 78-81. 5. Rooney JF, Bryson Y, Mannix ML, and others. Prevention of ultraviolet-light-induced herpes labialis by sunscreen. THE LANCET. December 7, 1991; volume 338, pages 1419-1422. 6. Peterman TA, Byers RH. Seasonal Variations in AIDS and Opportunistic Diseases. International Conference on AIDS, Washington, D. C., June 1987 [abstract # WP. 42]. 7. Flegg PJ. Potential risks of ultraviolet radiation in HIV infection. International Journal of STD and AIDS. January 1990; volume 1, pages 46-48. ***** Psychological Health and the Immune System by Jason Heyman Throughout the history of the AIDS epidemic there has been ongoing debate about the effects of psychological well-being and stress on the immune system. Current research is beginning to show scientific evidence of an effect, but controversy continues. At this year's International Conference on AIDS, a presentation by Jeffrey Burack, M. D. and others, reported that T-helper counts of depressed patients dropped 38 percent faster than those patients who were not depressed. His work, entitled "Depression predicts accelerated CD4 decline among gay men in San Francisco," studied 330 HIV-positive patients between 1985 and 1991. Dr. Burack explained the different mechanisms through which the treatment of depression might actually slow disease progression. "Depression has been shown to impair immune response in the laboratory, so there might be a direct effect of depression on the immune system. Also, depressed persons may be less likely to seek out or stick to appropriate medical care for HIV and may be more likely to engage in risky or unhealthy behaviors." Currently, Dr. Burack is collaborating with the Center for AIDS Prevention Studies (CAPS) in San Francisco on a study of interventions for HIV-related depression in gay men, called the Positive Education Project. The interventions include two types of group discussion sessions. One is informational, offering patients direct access to information about AIDS and the treatments they are taking. The other is a psychological/emotional support group. (For more information or to enroll call Derek Aspacher at CAPS, 415/597-9141). This program is just one of many studies looking at psychoneuroimmunology, a new field of science examining the interrelationship of psychology, neurology and immunology. Because of the large amount of research in the field, this article only addresses the psychological and social factors such as stress, depression, and social support. Basic Research On Psychological Factors and Disease Much of the most compelling research in this field has not focused on AIDS, but on other diseases such as cancer. While not directly applicable to AIDS, the results do give support to claims that psychosocial factors play a major role in the progression of disease. But their precise role in the pathogenesis of AIDS has not been determined. The most scientifically sound evidence of a relationship between stress and illness was detailed in "Psychological Stress and Susceptibility to the Common Cold," published in 1991 in the New England Journal of Medicine. In a carefully designed trial, research subjects were exposed to cold viruses and then quarantined and monitored for the development of symptoms. The researchers found that the rate of infection was directly related to psychological stress. Similar evidence was found in a Stanford University study on the survival of 86 women with metastatic breast cancer.(1) For one year, the women took part in group therapy sessions where they were encouraged to share their experiences and form bonds with the other women; they were also taught self-hypnosis to control pain. In a follow-up study ten years later, the researchers found that the women who participated in the psychosocial interventions lived an average of two years longer than those who did not. An intriguing fact about the study is that the researchers did not expect to see an effect. "We intended, in particular, to examine the often overstated claims made by those who teach cancer patients that the right mental attitude will help to conquer the disease." The study was mentioned October 4 in the New York Times Magazine in an article about the mainstreaming of alternative medicine. Current AIDS-Related Research The success of the Stanford study may soon be replicated with a group of HIV-positive people. A UCLA study led by Margaret Kemeny, Ph.D., is now offering free, intensive group therapy that will focus on quality of life and stress management. The project is the outgrowth of previous research by Kemeny, who found that chronically depressed people with HIV had a much steeper decline in their immune system over a five-year period.(2,3) The UCLA Group Therapy Project is now enrolling symptomatic, HIV-positive, gay and bisexual men between ages 25 and 45. (To enroll, call 310/206-7870.) In a comprehensive review of current research into the relationship between psychological health and AIDS,(4) Michael Antoni and Cornelis Mulder found that the stress of being HIV positive or having AIDS could influence the course of infection. In their review of about 40 studies, they examined the contradictory results, and found that many questions have yet to be answered. The majority of the studies, however, seemed to show a positive correlation. The authors were cautious about interpreting the positive results, but argued that they demonstrate the need for further research. Understanding the relationship between immune function and psychological state is very difficult, according to Leon McKusick, a psychiatrist with the CAPS program in San Francisco. For example, it is almost impossible to figure out if someone's depression is causing an immune dysfunction or that the reverse is true, that is, the immune dysfunction is causing depression. McKusick said that although it is generally accepted that some correlation exists, it has not been proven that a behavioral intervention has a direct effect on immune status. In the case of AIDS, he explained, it is very hard to determine causality. "Although we may all agree that one's psychology affects one's immune parameters, interfering might not help." Lydia Temoshok(5) has addressed these issues in her research, stressing that it is especially important to be precise in the measurements used to decipher data from clinical trials. Some of the confusion lies in the translation of research data into meaningful concepts because of the nature of HIV disease in which "...psychologic, neurologic, and immunologic changes occur as central, rather than as resultant or adjunctive, aspects of the disease process." A few studies have shown that interventions can have a direct impact on the immune system of HIV-positive people by enhancing psychological health. Researchers at the University of Miami studied the impact of an aerobic exercise training program on 39 gay men, 16 of whom were HIV positive and asymptomatic; the others were HIV negative.(6) After a five-week training period, the HIV-negative volunteers had average T-helper increases of 220, while the HIV-positive volunteers, who began with an average of 905 T-helper cells, only increased by 50. The researchers point to the sometimes minimal positive effects seen in anti- retroviral therapy and conclude that further research into the role of exercise for stress management should be pursued. The mental health of HIV-positive women was studied at the Beth Israel Medical Center in New York(7) and St. Mary's Hospital in London.(8) Both studies found high incidence of depression and stress. In light of current knowledge about the faster rate of disease progression in women, these researchers predicted that psychosocial factors are at the heart of the problem. Further research will be needed to prove or disprove this relationship. Other treatments that were reported at the conference to have some beneficial effect on psychological well-being are: art therapy, an attention training program, a 12-step recovery program, psychospiritual counseling, and social support. Comment A basic approach in traditional medical systems is the connection between mind, body and spirit, known as holism. In, for example, traditional Chinese medicine, this connection forms the basis for most medical practices. Psychoneuroimmunology seems to be Western science's attempt to understand and integrate these views. The word psychoneuroimmunology can itself be understood in its three parts; psyche (spirit), neuro (mind) and immunology (body). Both psychoneuroimmunology and holism are concerned with the interaction of these various parts, and the effect one might have on the others. Some of the controversy that surrounds holism also applies to psychoneuroimmunology. Critics argue that they both lead to a "blame the victim" mentality, by making a patient responsible for his or her own illness. On the other hand, the possibility of increased compliance with other therapies and improvement in the quality of life are positive aspects of this approach. Also, because psychological treatments and exercise do not have counter-indications with drug treatments, or any noticeable toxicities, they can be an effective complement to an HIV treatment strategy. But only when we have scientifically sound research on the importance of psychological health in a person with HIV will many more people take advantage of what seem to be very useful and safe treatments. Resources and References The Center for Attitudinal Healing offers free group therapy sessions for people with HIV or AIDS. An introduction to their services is offered every Thursday at 12:30 at their office, 19 Main Street, Tiburon, CA, 94920. For more information call, 415/435-5022. An organization has formed in Paris for PWA's interested in Psychoneuroimmunology. For information contact: Parsifal, B. P: 305, 75525 Paris, Cedex 11, France. 1. Spiegel D, Kraemer HC, Bloom JR, Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. THE LANCET. October 14, 1989; pages 888-891. 2. Kemeny ME, Duran R, Weiner H, Taylor SE, Visscher B, Fahey JL. Chronic Depression Predicts Immune Decline over a five year period. Presented at 99th Annual Convention of the American Psychological Association, San Francisco, August 1991. 3. Solomon, GF, Kemeny ME, Temoshok L. Psychoneuroimmunologic aspects of human immunodeficiency virus infection. In: Ader R, Felton DL, Cohen N (editors) PSYCHOIMMUNOLOGY II. Orlando FL: Academic Press; 1991: pages 1081-1113. 4. Muldur CL, Antoni MH. Psychosocial correlates of immune status and disease progression in HIV-1 infected homosexual men: review of preliminary findings, and commentary. PSYCHOLOGY AND HEALTH. 1992: volume 6, pages 175-192. 5. Temoshok L. On methods and models of research on Psychoneuroimmunology and HIV/AIDS. In Schmidt LR and others (editors)THEORETICAL & APPLIED ASPECTS OF HEALTH PSYCHOLOGY. London: Harwood Academic Publishers; 1990: pages 77-83. 6. La Perriere A, Fletcher MA, Antoni MH, Klimas NG, Ironson G, Schneiderman N. Aerobic exercise training in an AIDS risk group. International Journal of Sports Medicine. 1991; volume 12, pages S53-S57. 7. Bailer PA, Prenzlauer SL, Getter EV, Wallack JW. Psychological distress in HIV-infected women. VIII International Conference on AIDS, Amsterdam, June 19-24, 1992 [abstract #PoB3764]. 8. Sherr L, Melvin D, Petrak J, Davey T, Glover L, Hedge B. Women, AIDS and HIV infection -- psychological barriers and trauma. VIII International Conference on AIDS, Amsterdam, June 19-24, 1992 [abstract #PoB3426]. ***** HIV Treatment in Prison: Vacaville Update by Dave Gilden HIV-positive prisoners last month protested deteriorating conditions at Vacaville, California's main prison hospital for men, by refusing to take their medications. As many as 150 of the 330 inmates living in the facility's separate HIV unit participated. An exceptional number of fatalities sparked the action. These included two men whose failing physical condition was ignored for several weeks. They were finally removed from their cells at the point of death. In May 1991, AIDS TREATMENT NEWS interviewed the three doctors who then cared for Vacaville's known HIV-infected inmates [see AIDS TREATMENT NEWS #126]. At that time, we were impressed by the level of professional care for the inmates and by the personal concern these physicians felt for their patients. It was also clear that the doctors were continually frustrated by the the prison bureaucracy's indifference to patients' needs. All three practitioners (Jessica Clarke, M. D., Jan Diamond, M. D., and HIV Director German Maisonet, M. D.) left Vacaville last spring. Dr. Clarke now heads the HIV program at a private San Francisco hospital. Dr. Maisonet is an infection control specialist at the minimum security federal prison in Pleasanton, CA. Dr. Diamond first went on maternity leave and then was transferred to the state prison in San Quentin. Her new role, to enhance the state of medical care in San Quentin, results from a lawsuit against conditions there. Dr. Maisonet said of his decision to resign, "It hurt a lot to leave, but we were faced with an increasing number of patients and a decreasing amount of resources. I would have had to practice medicine at a level below the standard of care, and I wouldn't have been satisfied." To get a sense of the underlying problems, we talked with a number of ex-inmates and Vacaville staff members. The picture that emerges is one of poor management and lack of planning compounded by AIDS phobia. Prisons have a custodial mentality; "people can wait" is their attitude even when confronted with acute disease. The average age of prison doctors is 62. Many are ex- military officers in the prison system to collect a second pension. "How will they come up to speed on AIDS care?" asked one staffer. Free AIDS training is available for the few with the energy and the interest, but there is little incentive. Physicians are so poorly supervised that no one checks up on whether they actually see patients or how well they do. Monitoring for toxic reactions has been a particular weakness. This year, Vacaville received extra money from the state budget to hire three new AIDS doctors. In the meantime, Dr. Diamond is temporarily moving back to Vacaville. We talked to her about the general measures needed to improve HIV care at Vacaville and other California prisons. According to Dr. Diamond, "The key to improving health care is more oversight. Patients' records should be regularly reviewed by a second physician. Providing good HIV care is quite possible in the prisons. Any drug you want is available, and if you just stick to medical care, it isn't that busy." Asked about Vacaville's attempt to hire new HIV specialists, Dr. Diamond commented, "With the ever-growing health crisis and insurance mess, a lot of doctors in private practice are looking for other work. We should be able to hire physicians who are motivated to learn about AIDS and sensitive to treating inmates like people." The chief hurdle to the conscientious physician is the absence of support services. "German would spend 20 hours a week doing what a social worker should do," Dr. Diamond noted. In the past, no one did discharge planning for inmates with health problems. Released patients faced a bleak future unless their doctors shouldered the responsibility for finding them shelter and financial support such as disability payments. Partly due to the efforts of Drs. Maisonet and Clarke, the parole division of the Department of Corrections this year started a pilot discharge planning program for inmates from the Los Angeles and San Francisco regions. Getting help for patients with psychiatric problems has been another trying experience. HIV-positive inmates reside in separate housing units without access to the standard mental health department. They get only intermittent assistance for mental problems, even though HIV disease creates its own psychiatric problems and aggravates new ones. Those with advanced HIV dementia are generally warehoused in isolated cells known as "psychiatric management units." A violent prisoner affected by dementia is considered merely a disciplinary problem. Just breaking a window or throwing food at a guard can get someone placed in solitary confinement, which "can end up being quite damaging, quite inhumane," Dr. Diamond observed. An inability to hire more nurses further increases doctors' burdens. The nursing shortage restricts the size of Vacaville's acute care unit, meaning that severely ill inmates have to be sent at enormous expense to outside hospitals, interrupting the consistency of care. Meanwhile, the absence of an out-patient infusion center keeps prisoners with CMV retinitis in the acute care unit indefinitely so that they can receive their daily maintenance infusion of ganciclovir. If it weren't for these one-hour infusions, they could return to the residence units Inadequate support staff makes it hard to monitor for side effects. The number of treatments needed to manage AIDS- related conditions can multiply into the dozens, and many of these substances themselves require careful management based on frequent lab tests. "There is not enough appreciation of AIDS drugs' toxicity," Dr. Diamond noted. One area where she thinks too many drugs are given is in prophylaxis for candidiasis and cryptococcal meningitis. She feels that Pfizer Laboratories has promoted its product Fluconazole too aggressively for this use. Fluconazole costs $7 per day, and using it excessively might create resistant fungal strains. The Vacaville HIV service tends to give fluconazole to everyone with T-helper counts less than 200. Dr. Diamond instead recommends frequent screening for cryptococcus until a patient's T-helper count falls under 50. Prophylaxis with fluconazole should begin only at this point, unless the patient is already taking the drug for recurrent esophageal candidiasis or other reasons. Of course, this approach depends on timely lab testing. One way to overcome the lapses in staff support is to teach prisoners to recognize the symptoms of cryptococcal meningitis and other diseases so they can report them immediately. Prisoners could also learn to watch for signs of drug toxicities. A special aspect of self-help has been Vacaville's Pastoral Care Service. Sponsored by a prison chaplain, PCS is run by inmate volunteers who provide comfort to terminally ill prisoners. Without PCS, sick inmates in the hospital unit would be alone almost all day. The volunteers help the sick with basic physical functions, keep them company and intercede with the nurses to obtain needed care. Members of PCS sit constant vigil with inmates in the final days of their lives. "It's little short of a miracle that Father Leslie [the chaplain] got this done," Dr. Diamond commented. But Michael Haggerty, an inmate who coordinated Pastoral Care until his release last May, complains that Vacaville's new chief and associate wardens are much less supportive of PCS than the previous administration. PCS activities became sporadic, as approval and training of new volunteers were stalled and access to clients' living quarters denied. "It's hard for officials to see that inmates really want to help. It will be an ongoing proposition to get PCS entrenched," said Haggerty. All these comments apply only to the identified HIV-positive inmates. The unknown ones receive no HIV care at all. Surveys indicate that the total number of California prisoners with HIV is five to ten times the number known to be positive. Inmates avoid HIV testing because those found to be infected with HIV suffer from a variety of restrictions. The segregated housing units, bans on conjugal visits, and bans on working in food and medical department jobs discourage California inmates from obtaining what limited help there is for HIV-related conditions. Vacaville Prison Seeks HIV Physician The California Medical Facility in Vacaville seeks a physician with "good working knowledge of internal medicine and infectious disease in the HIV-infected patient. The physician will be administering health care to all categories of patient care from outpatient clinics, inpatient care, emergency services and screening examination of the HIV+ inmate." The position includes liability coverage. "Additionally, there is no office overhead, malpractice insurance or salaries to pay, and no billing or collection problems." For more information, contact Raymond L. Andreasen, M. D., Chief Deputy Warden(A), Clinical Services, P. O. Box 2000, Vacaville, CA 95696-2000. Or call Karen Huston, Examination Coordinator -- Personnel, 707/449-6532. AmFAR Announces Community-Based Research Grants: Letters Due November 5 The American Foundation for AIDS Research plans to award up to nine Operating Grants of up to $50,000 each, and up to six Project Grants of up to $100,000 each, to community-based clinical trials organizations within the United States and its territories, or (exceptionally) in other areas. Letters of intent (which must follow a specified form, including cover page, abstract, biographical sketch, and list of participating physicians -- with ten copies in addition to the original) must be received by 5:00 Eastern Standard Time on Thursday, November 5. Those whose letters are accepted will be given about six weeks to submit a grant application. For complete instructions on submitting the letter of intent, call the Community-Based Clinical Trials Program, American Foundation for AIDS Research, 212/682-7440. ***** AIDS TREATMENT NEWS Published twice monthly Subscription and Editorial Office: P. O. Box 411256 San Francisco, CA 94141 800/TREAT-1-2 toll-free U. S. and Canada 415/255-0588 regular office number 415/255-4659 fax Editor and Publisher: John S. James Medical Reporters: Jason Heyman John S. James Nancy Solomon Reader Services and Business: David Keith Thom Fontaine Tadd Tobias Rae Trewartha Statement of Purpose: AIDS TREATMENT NEWS reports on experimental and standard treatments, especially those available now. We interview physicians, scientists, other health professionals, and persons with AIDS or HIV; we also collect information from meetings and conferences, medical journals, and computer databases. Long-term survivors have usually tried many different treatments, and found combinations which work for them. AIDS Treatment News does not recommend particular therapies, but seeks to increase the options available. Subscription Information: Call 800/TREAT-1-2 Businesses, Institutions, Professionals: $230/year. Nonprofit organizations: $115/year. Individuals: $100/year, or $60 for six months. Special discount for persons with financial difficulties: $45/year, or $24 for six months. If you cannot afford a subscription, please write or call. Outside North, Central, or South America, add air mail postage: $20/year, $10 for six months. Back issues available. Fax subscriptions, bulk rates, and multiple subscriptions are available; contact our office for details. Please send U. S. funds: personal check or bank draft, international postal money order, or travelers checks. VISA, Mastercard, and purchase orders also accepted. ISSN # 1052-4207 Copyright 1992 by John S. James. Permission granted for noncommercial reproduction, provided that our address and phone number are included if more than short quotations are used. &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&