Date: 23 Dec 93 00:07 PST From: "John S. James" AIDS TREATMENT NEWS Issue #189, December 17, 1993 phone 800/TREAT-1-2, or 415/255-0588 CONTENTS: HIV and Psychiatric Treatments: Interview with J. Kevin Rist, M.D. IL-12: Potential Treatment Restores Immune Response in Laboratory Test Advanced AIDS: Alert for CMV Polyradiculopathy. Interview with Lawrence Drew, M.D., Ph.D. Voicemail Announcement System for Coordination at Conferences, Elsewhere AIDS TREATMENT NEWS Selected Index, Through 1993 ***** HIV and Psychiatric Treatments: Interview with J. Kevin Rist, M.D. by Denny Smith The debilitations of HIV are not always physical. Many people with HIV infection experience mental and emotional troubles that may contribute to the decline of their physical health, and yet be missed by physicians who are trained to focus on tangible illness. Like physical disease, however, psychiatric symptoms are often treatable. People who face ongoing depression or anxiety often find therapy or counseling valuable, and many community-based agencies can offer such therapy to people with HIV. Sometimes, however, a counselor or social worker will suggest a consultation with an HIV-experienced psychiatrist, who can offer pharmacological treatment when helpful. We interviewed J. Kevin Rist, M.D., to gain some insight into the psychiatric facets of HIV disease. Dr. Rist is an attending psychiatrist in the HIV Services department at St. Mary's Hospital and Medical Center in San Francisco. He also cares for a number of HIV-infected clients in his private practice. * * * DS: Is your treatment approach to HIV-infected patients significantly different from your treatment for other patients? KR: It's not very different from treating other patients who are also dealing concurrently with physical illness. For example, physical illness often means that these individuals are in fragile health and are already on a number of nonpsychiatric drugs. So you have to be aware of drug side effects, and interactions. Most of all, people come to us hurting or suffering, or needing something. It's not always comfortable for human beings to need something from, or to be dependent on, someone else. It's a vulnerable situation. I think it's particularly common for patients facing a life- threatening illness to get depressed, to feel anxious, to have sleep disturbances. DS: What would you say to primary care physicians who are not accustomed to assessing or treating psychiatric symptoms in their patients? KR: Physicians in other specialties are often very preoccupied, quite legitimately, with other things. But I think it's generally true that depression and anxiety are underdiagnosed in people with HIV, and if an internist can gain familiarity with treating psychiatric symptoms in their patients, that's good. Unfortunately, what I see a lot of, in patients referred to me by primary care providers, is the misprescription of benzodiazepine drugs: lorazepam (Ativan), diazepam (Valium), alprazolam (Xanax), flurazepam (Dalmane), temazepam (Restoril), triazolam (Halcion). I think that people perceive those drugs to be safe, but actually they are very addictive. You quickly build up a tolerance for them, and need more to obtain a therapeutic effect. Then both the patient and the doctor may find themselves in a quiet struggle over the issue, with the patient feeling guilty for wanting more and the physician feeling guilty for prescribing more, and the whole issue unnecessarily becoming an interpersonal one. If, instead, the physician were a little more savvy, and noticed some anxiety symptoms or trouble sleeping at night, he or she might ask more questions and realize these are really manifestations of depression, and treat them with the proper antidepressant medication, or refer them to someone who will treat accordingly. That way the patient will get better symptomatic relief, be more motivated to trust the doctor and work with the doctor, and avoid getting into a self-destructive cycle of being dependent on something that only their doctor can give them. DS: So the benzodiazepines are not antidepressants? KR: No, they are approved and marketed for various other indications, such as immediate anxiety. They are not appropriate for long-term therapy. Using them to treat depression is a little like treating a serious fever with aspirin, without delving further into the underlying cause of the fever. If someone is extremely troubled, I may offer a benzodiazepine like lorazepam along with an antidepressant like imipramine, and taper off the lorazepam as the antidepressant takes effect, which can take several weeks. I've seen patients who were actually on two different benzodiazepines-one for anxiety and one for sleeplessness. That kind of combination can cause cognitive impairment and even be dangerous, especially when mixed with alcohol. So rather than treating every symptom with a different medicine, I like to see people on simplified, clean regimens of psychiatric medications. DS: On a related note, a lot of people with HIV have a history of recreational drug use, and a lot of people with a history of chemical dependency are now HIV-infected. And yet we are perhaps finally emerging from the Reagan/Bush approach to drugs, now considered essentially a nonproductive social policy. What is a productive attitude in the 90s? KR: I want patients to feel safe to talk about drug use. If someone is now using drugs, I talk to them about what they want to do with their life. You can be clear that you don't approve of something that's not in their best interest, and still maintain a mutually respected position with each other. You can express disapproval of a behavior rather than a person. With a punitive or a "just say no" approach, you're just going to lose the patient; you have no chance of helping someone who leaves your care. So the first question I ask on this issue is "Are drugs or alcohol a problem for you--have they ever caused you any negative consequences?" If the answer is "No," and I don't perceive any problems, like elevated liver enzymes, then the issue is set aside. If the answer is "Yes," or "Sometimes," then I ask "Why do you continue using them--would you like me to help you with this?" It is not productive to be judgmental. If you want someone to be capable directing their own life, then on some level you have to be comfortable with them directing their own care. DS: Which psychiatric drugs are appropriate in the context of HIV care? KR: Except for the benzodiazepines, I'll rely on the traditional antidepressants, such as the tricyclics-- amitriptyline (Elavil), imipramine (Tofranil), nortriptyline (Pamelor)--as well as the newer generation, such as fluoxetine (Prozac) and sertraline (Zoloft). Although these are specifically indicated for treating depression, by extension they can also relieve anxiety and problems sleeping. I think that low-dose antipsychotics, such as perphenazine (Trilofon), are good for treating overwhelming anxiety, or psychotic depression, especially in patients who have not responded to the other drugs. DS: How do you distinguish depression and anxiety from the early symptoms of dementia? [For a larger discussion of cognitive and motor deficits, see AIDS TREATMENT NEWS issue number 171, March 19,1993.] KR: It's important to remember that most cognitive impairment is not dementia. First, of course, you are obligated to look for any life-threatening opportunistic diseases, using whatever neurologic tests are appropriate--MRI [magnetic resonance imaging] or LP [lumbar puncture], etc. Then you ask if drugs are a factor, either prescribed or recreational drugs. Then you try to rule out psychiatric symptoms, such as depression. HIV-associated dementia is the remaining diagnosis to make in the situation. DS: For a number of years, the dominant mental health model of "how to be" a person with AIDS was basically a death and dying model. It was not a monolithic model, but the aggressive treatment approach largely took a back seat to the acceptance of death. There are still health care providers who routinely refer to HIV infection as a terminal illness, rather than a life-threatening disease. How is it possible to view HIV as something to survive, or at least to live with? KR: Having HIV now should be seen as dealing with a chronic illness. I have at least two patients who are long-term survivors. Neither of them ever expected to remain healthy or even to be around this long, and they have had to find the strength to survive the losses all around them. One of them was once told that he had only six months left to live. That was ten years ago, and people like him now present the psychiatric community with a whole new set of issues, including how to live when you didn't expect to, how not to die. ***** IL-12: Potential Treatment Restores Immune Response in Laboratory Test by John S. James IL-12, a newly-discovered substance which is naturally present in the body in small amounts, has been found to restore certain immune responses which are diminished or lost in HIV infection.(1) This result, recently published by researchers at the U.S. National Cancer Institute, was found in cells of HIV-positive donors. IL-12 was administered to these cells in a laboratory test. IL-12 has not yet been tested in humans, but clinical trials are expected in 1994. [Note: Do not confuse IL-12 with IL-2, another immune modulator which is also being tested as a potential AIDS treatment.] Two of the researchers on this study, Mario Clerici, M.D., and Gene M. Shearer, Ph.D., proposed a theory earlier this year of a "TH1-to-TH2 switch" -- a change in immune function which occurs in HIV infection, and may cause the disease to progress faster.(2) According to this theory -- which is accepted by many but not all researchers -- in early HIV infection, the body first defends itself effectively against the virus by one kind of response (called the TH1 response; 'TH' stands for T-helper); this response consists mainly of cellular immunity, i.e. certain cells which destroy infected cells. But then, while the patient is still asymptomatic, the immune system switches to a TH2 response, which mainly produces antibodies, which appear to be less effective than cellular immunity in controlling HIV infection. Each kind of response tends to suppress the other; so when the switch to a TH2 response occurs, the protective TH1 response is largely lost. IL-12 may reverse this switch and restore cellular immunity against HIV and other pathogens. Two teams, Genetics Institute, Inc., Cambridge, Massachusetts, working with the Wistar Institute, Philadelphia, Pennsylvania, and Hoffmann-La Roche, Inc., Nutley, New Jersey, each independently discovered IL-12. Genetics Institute and Wistar initially named their discovery Natural Killer-cell Stimulatory Factor (NKSF). Roche named its discovery Cytotoxic Lymphocyte Maturation Factor (CLMF). Genetics Institute and Roche have agreed to cross-license each other so that each company may proceed independently in the further development of IL-12. A December 10 news release from the National Cancer Institute explained the new IL-12 study. It is the best description for non-scientists, so we reproduce it in full: "National Cancer Institute (NCI) scientists have succeeded in restoring normal immune responses to cultured cells from HIV- infected donors. The scientists used a natural blood substance, interleukin-12 (IL-12), which will be tested in asymptomatic HIV-positive individuals within the next several months. HIV is the virus responsible for AIDS. "T lymphocytes from many HIV-infected people do not show normal immune reactions when they are exposed to antigens such as influenza virus. By adding the immune regulator IL-12 to cultures of these cells, the NCI scientists and their colleagues were able to augment the cells' immune reactions. "'In the test tube, this is the most powerful immune response modulator we have seen,' said Gene M. Shearer, Ph.D., of the National Cancer Institute's Experimental Immunology Branch. "IL-12 was identified in 1991 by scientists at the Wistar Institute, Philadelphia, and Hoffmann-La Roche, Inc., Nutley, New Jersey. It is an interleukin -- one of a class of proteins produced by lymphocytes that transmit signals to regulate growth of immune cells. "Mario Clerici, M.D., Shearer, and their colleagues at NCI and the National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, along with researchers at Lackland Air Force Base, San Antonio, Texas, and Genetics Institute Inc., Cambridge, Massachusetts, performed the current study, which appears in the December 10 issue of Science. "The investigators tested white blood cells from HIV-negative and HIV-positive individuals by exposing cultures of the cells to several antigens, including influenza virus and synthetic versions of HIV envelope peptides. Cells from HIV- negative donors reacted to antigens with T-cell proliferation, interleukin-2 (IL-2) production, and interferon-gamma (IFN-gamma) production. (These cells did not react to the HIV envelope peptides, however, because of the donors' lack of previous exposure to HIV.) "Cells from HIV-positive individuals did not respond fully to any of the test antigens unless IL-12 was added. In the presence of IL-12, the cultures reacted normally to challenge with the antigens, showing T-cell proliferation, IL-2 production, and IFN-gamma production. The immune responses of cells from HIV-negative donors were normal whether or not IL- 12 was added. "Shearer and Clerici have previously shown that, in HIV- infected individuals, a switch from one pattern, type 1, of interleukin production to a different pattern, type 2, is associated with disease progression. The type 1 pattern principally enhances cellular immunity, while type 2 is linked with antibody production. Because Shearer and Clerici believe that cellular immunity is more effective than antibodies in combating HIV infection, they have been interested in finding ways to promote the type 1 pattern. The results of the current study suggest that IL-12 may have this effect. "NIAID scientists recently tested IL-12 in mice with a disease similar to AIDS and found that it had a positive effect on the animals' immune function (Ricardo Gazzinelli, Ph.D., and others, unpublished results). Preliminary (phase I) studies of IL-12 in HIV-infected people are being planned by the manufacturer, Genetics Institute, Inc., and should begin in the first half of 1994." References 1. Clerici M, Lucey DR, Berzofsky JA, and others. Restoration of HIV-specific cell-mediated immune responses by interleukin-12 in vitro. SCIENCE. December 10, 1993; volume 262, pages 1720-1724. 2. Clerici M and Shearer GM. A TH1-->TH2 switch is a critical step in the etiology of HIV infection. IMMUNOLOGY TODAY. March 1993; volume 14, number 3, pages 107-111. ***** Advanced AIDS: Alert for CMV Polyradiculopathy. Interview with Lawrence Drew, M.D., Ph.D. by John S. James Persons with T-helper counts under 50 who have a sudden weakness in the legs -- especially if there is any loss of bladder control -- should get medical attention immediately to see if they have a neurological CMV infection called CMV polyradiculopathy. If so, they need to start treatment immediately with ganciclovir (or possibly foscarnet). The treatment is the same as for CMV retinitis. This condition is rare, occurring in perhaps only one percent of people with AIDS. But doctors are seeing more of it today, since AIDS patients are living longer. Many physicians are not familiar with this condition. So we interviewed Lawrence Drew, M.D., Ph.D., a CMV expert at Mt. Zion Hospital in San Francisco, who brought the matter to our attention. There is also a literature review and report of two cases which was published last July.(3) JJ: Who should be on the alert? Only people with a CD4 count (T-helper count) under 50? LD: I think so. This is a late manifestation of AIDS, and even late for CMV. We haven't had anybody with a CD4 count above 50. They may well have already had CMV retinitis, but not necessarily. Neurological abnormalities in the legs can be caused by many different problems -- either HIV itself, or the drugs used to treat it. When you have tingling, that's likely to be peripheral neuropathy, caused by either HIV or the drugs. But if you get true weakness of the legs, especially with a loss of bladder control, in a patient with CD4 count under 50, those would represent a warning sign about this syndrome. Maybe two thirds of patients with this condition have a bladder problem. Pain can also occur, but that can happen with peripheral neuropathy also. The doctor examining the patient also finds an absence of reflexes in the knee and/or the ankle; that can happen with the neuropathy too. People with a change, especially if reflected by weakness in the lower legs, and maybe an intensification of pain, should at least see the doctor, especially if they're not on ddC or ddI [which can cause symptoms which may be confused with CMV polyradiculopathy]. JJ: What should the doctor look for? LD: The examination will show absent reflexes, or highly diminished reflexes, as well as muscle weakness. If there is not an evident explanation, like ddC or perhaps ddI, and if there is any suggestion of a bladder problem, that might help the doctor suspect this condition. What has to be done to make the diagnosis is a spinal tap -- something that many patients are reluctant to have, although it's not that difficult or invasive. The findings in the spinal fluid are very characteristic, very unique. JJ: Will most medical labs be able to diagnose this properly? LD: They have to be on the lookout, and be aware of this condition. The pattern in the spinal fluid -- the cell response, the glucose, and the protein -- are very typical, and very unusual for a virus. It looks like the pattern of a bacterial meningitis -- low sugar, and high white count, polymorphonuclear cells. These two together -- spinal fluid test results that look like bacterial infection, but the fluid does not grow bacteria -- should be a major alert to the doctor and the laboratory. Together with the clinical picture, you should begin treatment for CMV on that basis. We do know that you get a reduction in viral signal in the spinal fluid, when you treat with ganciclovir. We have shown that in two patients now, using the new Chiron bDNA assay. [For background on the bDNA (branched DNA) viral test, see AIDS TREATMENT NEWS #186, November 5, 1993. In this case, the test has been adapted to test for CMV, instead of for HIV.] This is important because there have been questions about how well either ganciclovir or foscarnet get into the spinal fluid. JJ: Can foscarnet be used for treating this condition? LD: We have not yet had the opportunity to test with foscarnet [to see if it lowers viral activity in the spinal fluid, as ganciclovir apparently does]. And there are not enough cases in the literature at this time to know which of these two drugs would be better. If you had a patient already being treated with ganciclovir and this problem appeared while they were on it, my instinct would be to use foscarnet. [Note: a recently published report of a case where this happened found that the virus was resistant to ganciclovir -- supporting the decision to use foscarnet instead.] JJ: Any other information we should include? LD: The main point I would emphasize is that late treatment has been disappointing -- usually either no response, or a minimal arresting of the disease. Since the drugs evidently do get in, and are active against the virus, too extensive disease may have occurred by the time the diagnosis has been made. So the hope is to identify this condition earlier, and treat immediately. This should be viewed as an emergency, because it is very disabling if not arrested early. There are also cases where patients respond only after weeks or months of treatment. Although this is a rare condition, patients and physicians should keep in mind these red flags, the clinical symptoms and what the physician needs to know. Patients may need to bring the information to their physician's attention, if that individual has not had any experience with this problem. References 1. Kim YS and Hollander H. Polyradiculopathy due to cytomegalovirus: Report of two cases in which improvement occurred after prolonged therapy and review of the literature. CLINICAL INFECTIOUS DISEASES. July 1993; volume 17, pages 32-37. Note: At this time there are at least six references to CMV polyradiculopathy in the AIDSLINE computer database of AIDS medical articles. ***** Voicemail Announcement Systems for Coordination at Conferences, Elsewhere by John S. James This article stems from our recent experience covering a large AIDS conference in Washington, D.C. About a thousand people attended, including about 20 AIDS treatment activists from several cities. In such situations, activists sometimes meet before the conference to share information about what is "hot," what is new and most important; there are many simultaneous meetings, so people must choose, and the official program seldom tells the real story. But often the activists do not get coordinated until the conference is mostly over, meaning that their time at the meeting is not used as well as it could be. Not only do they miss important official sessions, but they lose opportunities for special- focus dinner meetings and other informal gatherings, where valuable contacts could be made. [This is a big problem for everyone at international AIDS conferences, such as the upcoming August 7-12 1994 meeting in Yokohama, Japan. These world AIDS gatherings, each with about ten thousand participants and thousands of meetings and other presentations packed into five or six days, have traditionally compounded the information overload problem by refusing to release much information in advance -- a bit of "corporate culture" left over from the early days of the epidemic, and difficult or impossible to change because a different group in a different country handles the arrangements each year. We believe that the ultimate solution is to computerize AIDS teamwork and communication when possible, making the same information available throughout the world at all times. For example, conference abstracts and other presentations should be publicly available by computer as soon as they are submitted, even before they are refereed. People will still go to the meetings.] One partial solution now is for activists (or other groups with a shared interest) to rent a local voicemail system, during a conference and for a few days before and after it, to use as a telephone announcements line. Perhaps five, ten, or twenty people would be given a code to add messages to the outgoing announcement; these new messages would instantly be available to all callers. Everyone interested would be given a phone number to call to hear the current announcements, starting with the most recent. They would not need any instructions for using the system; just call and listen for what's new, then hang up when you get to the older messages which you already heard in a previous call. Because the new messages play first, it's easy to call several times a day to keep in touch with the latest information. The same kind of system could also be used permanently in a city, as an improvement over the "events tapes" which many organizations have used for years. The problem with most of the events tapes is that the whole tape has to be re-recorded in order to make any addition or change to the message. As a result, the messages are not current, but are likely to be updated only once a week or so, or at most once a day. With a voicemail announcement system, anyone authorized to add an announcement only needs to call it in. Specifications: What an Announcement System Should Do? We are now investigating voicemail systems to see which ones have the features needed for this special use, for example: * Messages must be added to the outgoing announcement which anyone can hear -- not to a voice mailbox which only those with a special code can listen to. * The announcement must play the most recent additions first -- so that callers don't have to wait through old news they have already heard before learning if there is anything new. * The average caller should not need any special instructions, and not need to use a voice menu. Just call and listen -- from any phone, even a rotary-dial phone which cannot transmit tones to control the equipment. * A code, such as a four-digit number, will allow only authorized callers to add messages to the outgoing announcements; each new announcement must be available immediately to all subsequent callers. Persons without the code who learn about something interesting should be able to leave a message in a voice mailbox (after the outgoing announcement finishes); those with the code should be able to hear this message, and to transfer it into the outgoing announcement if they choose to do so. * An additional code could be used to keep the entire system private, if desired. Callers would have to enter this code to hear the outgoing announcements. (This secrecy could be discreet, by having the system play a standard announcement asking callers to leave their message, which would be recorded as with standard voicemail; only callers who entered the code during or after this standard outgoing message would hear the announcements. This avoids making people angry by having the system hang up on them because they don't have the code.) * Multiple phone lines should be available, so that at least two callers can dial the same number and use the system simultaneously. * Callers should be able to skip forward and backwards within a message, and also to the next/previous message. * The system administrator should be able to find out how many people have called, and when. Ideally, the cumulative number of calls so far should be available at any time by telephone, through use of a special code. [This master code should also allow the administrator to assign or change the codes which allow others to add outgoing announcements -- and to call in and learn which code was used to add each announcement. This way, several organizations can share the responsibility of updating the information; and if a code gets out and is abused (for example, to add false announcements), it can be revoked selectively.] Systems with all these features do exist, or soon will. Renting a service can start at about $25 per month, regardless of the number of incoming calls; so operating a voicemeil announcement line is within the financial reach of most organizations. Request for Information If you can recommend a voicemail system for such use -- or know how we might find one in Yokohama -- call AIDS TREATMENT NEWS at 800/TREAT-1-2, or 415/255-0588. We hope to provide such a system at the Yokohama conference. We are also considering setting up a permanent system, open to everyone, in San Francisco. ***** AIDS TREATMENT NEWS Selected Index Through December 1993, Issue #189 Compiled by Thom Fontaine and Denny Smith 3TC (lamivudine) Issues #140,173 5-fluorouracil/5-FU 122,129 566C80 (atovaquone)(mepron) 108,109,114,123,129,133,139,160,164 8th International Conference 153,154,155,156,157,159 9th International Conference 175,177,178,181 10th International Conference 187 acemannan 157,182 ACT UP 146,147,165,188 ACTG 116A 167 active ether lipids 181 activism 130,147,151,164,188 acupuncture 130,157 acyclovir (Zovirax) 83,94,108,115,132,133,143,165,168 adrenal glands 140 aerosol pentamidine 88,90,114,129 African traditional medicine 166 AGM-1470 135,141,162. 188 albendazole 129 allergies 181 alpha APA 159,171 alpha interferon 75,87,101,119,122,133,154,155,179,185 alternative & traditional treatments 153,157,158,166 alternative treatment library 184,186 amikacin 109 amphotericin B/liposomal AmB 41,58,117 Ampligen 67,119 anabolic steroids 166,187 anal cancer 184 anemia 82 angiomatosis 129 Antabuse (disulfiram) 29,70,132 anti-angiogenesis 117,122,135,141 anti-idiotype antibody therapy 93,110 antidepressants 189 antioxidant 152 antisense 141,185,187 antisense RNA 187 antivirals 158,164 aphthous ulcers 133 apoptosis 181 Asacol 109 aspirin 109,118,183 ateviridine 183 atovaquone (566C80) 123,129,133,139,160,164 AzdU (azidouridine,CS-87) 72 azithromycin (Zithromax) 75,79,108,109,111,113,124,132,133,136,139,152 AZT (zidovudine,Retrovir) 83,86,100,107,110,113,115,121, 132,137,141,143,144,145,150,154,155,158,166,167,173,177,183 bacillary angiomatosis 129 bacteremia 129 bacterial infections 120 Bactrim (co-trimoxazole,TMP-SMX) 79,108,114,123,129,147, 152,161 benefits 74,76,105,144 Berlin Conference 177,178. 181 beta carotene 134,158 beta-lapachone 174 BHAP 183 BHT 10,71 BI-RG-587 117,125,127 biological response modifiers 120,122 bitter melon 155,157 bleomycin 73,122 blue-green algae (sulfolipids) 87,99 breast cancer 145 British AIDS Funding 175 buyers' clubs 143,144,145,167,176,188 BV-ara-U 146 cancer 93,110,112,118,122,126,135,139,162,174 candidiasis (thrush) 37,96,133 capsaicin (Axsain,Zostrix) 121 CD4 (recombinant soluble) 62,158 CD4-PE40 130 CD8 expansion 151 CDA (chlorodeoxyadenosine) 93,110 cervical cancer 184 chemotherapy 73,75,93,110,122,135 children/infants 90,114,120,123,124,130,174 Chinese medicine 61,68,71,75,93,107,126,153,158 chiropractic 130 cholera 152 chronic fatigue syndrome (CFIDS) 93,132 cimetidine (Tagamet) 80,122 ciprofloxacin 152 clarithromycin 109,113,124,129,137,139 clindamycin 79,104,108,111,129 clinical trials 116,141,144,149,154 clofazimine (Lamprene) 79,141 CMV 71,76,83,89,94,96,108,110,124,129, 133,138,146,149,167,168,171,179,189 CMVIg 168 coenzyme Q-10 (ubiquinone) 26,119,124 cofactors 83,108,119,124 colitis 133 combination therapies 107,115,119,145,149,150,154,155,156 community research 65,66,83,85,105,143 compound Q (trichosanthin) 82,88,99,104,119,155 computerized information 83,102,114,116,124,154,165 Concorde Study 173,177 conocurvone 182 convergent combination therapy 170 cortisol 140,150 cosalene 183 CPFs 108 cryotherapy (liquid nitrogen) 122 cryptococcal meningitis 41,58,96,99,117,129 cryptosporidiosis 49,58,75,80,95,107,111,113,124,129, 133,139 curcumin 174,176,177 cytarabine (ARA-C) 79,93,129 d4T (stavudine) 72,158 159,161,166,185 dapsone 79,114,125,129 daraprime (pyrimethamine) 79,104,108,114,129 daunorubicin (DaunoXome) 117,122,174 ddC (HIVID) 89,103,104,112,113,115,132,141,144, 145,149,150,154,155,166,167 ddC/AZT 115,132,145,150,154,167 ddI 83,88,99,103,110,112,125,131,137,141, 149,150,160,166,167,185 ddI/ d4T 185 ddI/AZT 167,168 delavirdine (BHAP) 183 dementia 97,101,156,171,189 depression 184, 189 desensitizaton 147,161,180 dexamethasone (Decadron) 79,88,93,150 dextran sulfate 50,76,89 DHEA (EL 10) 48,49,84,140,150 diagnosis accuracy 100,111,119 diarrhea 133,141 diclazuril (Clinicox) 80,95,107,111 disability regulations 144 DNCB 14,116,157,182 doctor/patient relations 100,111 doxil 184 doxorubicin (Adriamycin) 73,122,174 doxycycline 95,104,108,119,124,129 dronabinol 131,133,141 DTC (Imuthiol) 29,70,114,131,132 e-mail 172 eflornithine (DFMO) 94,95 encephalitis 79,97 endocrine problems 140,150 enteritis 133 eosinophilic folliculitus 161 epidemiology 97,99,124 EPO (erythropoietin) 82,150 Epstein-Barr Virus (EBV) 93 erythromycin 129 esophagitis 133 ethyloxime 25 181 etoposide (VP-16) 73,122,149,168 exercise therapy 157 eyesight 171 FAACTS 119 fansidar 42,108,114 fatigue 184 FDA 175,176,180 fetal tissue research 164 FIAC 94 FIAU 129,133 Flagyl (metronidazole) 129 FLT (fluorothymidine) 72,119,145 flu shots 138,185,187 fluconazole (Diflucan) 41,58,80,96,103,129,133 folic acid (folate) 134 foscarnet (Foscavir) 71,83,94,108,110,129,133,136,138,168 fumagillin 122,135 funding/lobbying 97,99,111,145,151,156,157,173,174 fusidic acid (Fusidin) 42,79 Fusion Toxin 176 G-CSF (neupogen) 122,167 gall bladder 124,133 gamma globulin 152,155 ganciclovir (DHPG,Cytovene) 71,89,94,96,108,124,129,133, 138,167,168 ganciclovir eye implants 167 gastritis 133 gastrointestinal manifestations/HIV 133 GEM-91 185 gene therapy 158 gentamicin 109 germanium 90 Global AIDS Action Network 187 glutathione 88,92,93,119,121,152,157,187 glycyrrhizin 17,103,115,181 GM-CSF 87,93,94,105,108,110,122,167 gp120 (vaccine) 130,149,174 gp160 (vaccine) 130,152,174,183,185 health care politics 99,103,111,112,120,125,126,132,135, 136,137,179 hearing 171 hemophilia 89,102,103,132,137 heparin,substitutes 100,122,146 hepatitis 126,133,146 herpes/shingles 80,83,94,100,115,133,138,143,146,149 HGP-30 (vaccine) 130 histoplasmosis 41,96 HIVIG (HIV hyperimmune globulin) 153,154,158 HPMPC 76,96,149 human papilloma virus (HPV) 146 Humatin (paromomycin) 107,111,129 hydrogen peroxide 49,132,134,152 hydroxyurea 178 hypericin 80,86,88,91,96,117,125,138,141,146, 155,167,168 hyperimmune milk (colostrum) 49,95,107 hyperthermia 104,122 ibuprofen (Advil) 109 idarubicin 122 IGF-1 146,150 IL-12 189 immigration politics 89,98,114,120,125,128,129,134,150, 170,177 immune globulin (IVIG) 119,120,124,129,148,152,154,168 immune restoration 151,169 immunomodulators 119,151,158 immunosupressive peptide 181 immunotoxins 140 Imuthiol (DTC) 29,70,114,131,132 indomethacin 109 influenza A 187 insurance 74,76,120,136 interferons 75,87,101,108,114,119,122,132,151 interleukins (IL-2,etc.) 119,122,151,186 international edition,ATN 155,159,173 international travel 128,152 iscador (mistletoe compound) 92 Isis 2922 187 isoprinosine 106 ITP 48 itraconazole (Sporanox) 80,96,161 IVIG 148,153,154,168 Kaposi's sarcoma (KS) 73,75,87,99,100,117,122,129,135,162, 168,174,184,185,188 Kemron 97,101,114 ketotifen 158 L- carnitine 183 L524 184 L661 & L229 139,169,170 L671,329 & L687,781 114 L697,639 & L697,661 118,125 labor unions 123 lacquered mushroom 157 laser treatments 75,96 lentinan 19,73 letrazuril 133 leucovorin 49,52,79,108 levamisole 119,122,124 lignins ( natural & synthetic) 158 liposomal doxorubicin 184 liposomes 109,117,122 lipsomal daunorubicin 168 liquid nitrogen (cryotherapy) 122 lithium 119 liver problems 103,133 long-term survival 175,178 LTR 174 Lyme disease 132 lymph nodes 172,182 lymph tissue 153 lymphoma 93,110,136,140 MAI/MAC 109,113,124,129,132,136, 137,139,141,149,152,158,188 marijuana 131,133,139,141,148,156 Marinol 131,133,141,148 mebeciclol 95 medical research funding 163 megace (megestrol acetate) 76,77,133,150,183 MEK 99 melanin 107,139,141,144 melitten 181 meprone 123,133,139,164 mexiletine 121 microsporidiosis 129,133,139 mitoxantrone 93,122 MM-1 57 molluscum contagiosum 133 monoclonal antibodies 129 MSL-109 168 mycoplasma 95,108,124,129 myopathy 119 N-butyl-DNJ (deoxynojirimycin) 149 N-of-one trials 153 NAC 88,92,93,119,121,138,141,152,157,184 naltrexone 16,52,119 nanoparticles 181 National Task Force 188 nausea 131,139,141 neopterin 86,100 neupogen (G-CSF) 122 neurologic disorders 171 neurology 156 neuropathy 121,130,156 neuropsychiatric concerns 97,101,126 neutropenia 94 nevirapine 170 NF-kB (NF-kappaB) 187,188 nonsteroidal anti-inflammatories 109 nutrition/malnutrition 73,133,134,141,152,158,163,181 octreotide (Sandostatin) 58,95,127,141 on-line computer systems 154 Oncolysin B 136 oral interferon 97,101,114 ozone 80 p24 (vaccine) 130 p24 antibody 100,119 p24 antigen 100,119 pain medication 154 parallel track 82,84,85,104 parasites 133 passive immunotherapy 67,92,148,149,151,158,165 pathogenesis 147,156 patient / doctor relations 100,111 patient drug assistance program 186 PCR 62,144 peliosis hepatis 129 pentamidine 114,129 pentosan polysulfate 117,122 pentoxifylline (Trental) 133,145,156,158,185 people of color 86,99,121 Peptide T 84,119,126,178 Persantine (dipyridamole) 79 pets (infection hazards) 79 PF4 (recombinant) 122 pharmacies 64,86 physician interviews 106,119,124,126,132,135,142,143,149, 160,166,171,175,176,179,184,186,189 piritrexim 122 PMEA 156 PML 79,88,100,115,129,153,156 Pneumocystis (PCP) 58,83,90,106,114,115,123,129,139,147 pneumonias,bacterial 119 polio vaccine 147 political funerals 157,160 polyadenylic-polyuridylic acid 158 poppers 160,187 prednisone 150 pregnancy 90,112,153,154 primaquine 113 prisons 106,125,126,130,149,151,161 probenecid 86 procysteine 152 programmed cell death (apoptosis) 156 prophylaxis/prevention 79,90,94,100,106,108,114, 119,123,129,158,161 propolis 37 Prosorba column (protein A) 75,122 protease inhibitors 117,156,184 psychiatric treatment 189 psychological health 161 pyridinone (L661) 169,170 pyrimethamine (Daraprim) 79,104,108,114,129 R 82913 131 R-HEV test 85 radiation therapy 73,93,110 recombinant human growth hormone 187 recombinant platelet factor 4 (rPF4) 185 recreational drugs 119 research priorities & policy 77,78,104,105,110,112,124, 126,127,136,140,142,145,146,150,151,152,155,156,157, 158,167,168 resource list 143,144,145,167,170,187 reticulose 98 retrogen 158 reverse transcriptase inhibitors 117 ribavirin 141 ribozymes 171 ricin-A 140 rifabutin (Ansamycin) 53,79,109,129,149,158,160 rifampin 79,102 rimantadine 187 Ro 24-7429 (tat inhibitor) 141,142,153,166 roxithromycin 75,81,95 Salk vaccine (HIV) 98,130 Sandostatin (octreotide) 58,95,127,141 scabies 98 SCH 39304 99 Septra (co-trimoxazole,TMP-SMX) 79,108,114,123,129,147, 152,161 shiitake 19 Sjogren Syndrome 181 snake bush 182 Social Security guidelines 144 SP-PG 135,141 sparfloxacin 129,132,152 speech 171 spiramycin 49,79,95,107 stem cell research 151 steroids 114,115,133,150,166,187 sulfa desensitization 161,180 sulfadiazine 79,93,104,108,129,168 sulfolipids (blue-green algae) 87,99 sunlight. 58,124,161 superantigens 151 surrogate markers 119,144 symptoms 100,119,124 syphilis 124 T4-helper (CD4) cells 119,144,147 tat inhibitors 127,128,132,141,142,153,166,167,174, 187,188 taxol 188 tests (blood values) 119,144,151 TH1-to-TH2 switch 189 thalidomide 133 THF (thymic humoral factor) 151,168 thymopentin (TP5) 123,149,168 thymosin (thymic hormone) 151 TI-23 108,129,168 TIBO derivatives 97,131 TLC-G-65 109 TNF 87,88,145,156 TNP-470 162,188 toltrazuril (Baycox) 111 topotecan 174,178 toxoplasmosis 79,104,108,109,113,123,124,129,139,152 TPN feedings 133 transfer factor 47,119 travel 152 treatment access 83,84,85,115,116,118,119 treatment information sources 162 treatment strategy 83,100,111,119,124 trental 133,145,156,158 tretinoin (Retin-A) 122 trifluridine (Viroptic) 115 trimethoprim/sulfamethoxazole 79,108,114 trimetrexate/leucovorin 49,52,108 tuberculosis 106,161 tumeric 174,176,177 tumor necrosis factor 87,88,145,156 typhoid fever 152 ultraviolet light 161 vaccines 130,149,151,152,164,174,185 valley fever (coccidioidomycosis) 41,96 Velban (vinblastine) 73,122 vidarabine (Vira-A) 79,94 vinblastine,(vincristine) 73,122 viral quantitation 144,153 vitamin A 134,158,185 vitamin B 134,152,158 vitamin B-12 158,171 vitamin C 111,152,157,158 vitamin D3 analogs 122 voicemail 189 warts 112,118 wasting/weight loss 76,77,88,119,134,141,146,166,187 WF-10 162 women 65,90,111,112,115,118,130,153,154 yohimbine 158,159,166 zinc 134,158 zovirax (acyclovir) 108,115,132,133,143,165 ***** 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 fax: 415/255-4659 Internet: aidsnews.igc.apc.org 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 1993 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.