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HICNet Medical News Digest Sun, 02 Apr 1995 Volume 08 : 
Issue 13

Today's Topics:

 Daily AIDS News Summary

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 Jack E. Cross, B.S Health Care Admin, 882 Medical Trng Grp, USAF

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To: hicnews

 AIDS Daily Summary

The Centers for Disease Control and Prevention (CDC) National AIDS
Clearinghouse makes available the following information as a public
service only. Providing this information does not constitute endorsement
by the CDC, the CDC Clearinghouse, or any other organization. 
Reproduction
of this text is encouraged; however, copies may not be sold, and the CDC
Clearinghouse should be cited as the source of this information.
Copyright 1995, Information, Inc., Bethesda, MD

 In this issue:
 
*********************************************************************
 "India to Become AIDS Epicentre, Conference Told"
 "Treatment of Cytomegalovirus Retinitis With an Intraocular
 Sustained-Release Ganciclovir Implant: a Randomized Controlled
 Clinical Trial"
 "Gene Therapy and Immune Restoration for HIV Disease"
 "Debugging Blood"
 "Adverse Cutaneous Reactions to Trimethoprim-Sulfamethoxazole in
 Patients with the Acquired Immunodeficiency Syndrome and
 Pneumocystis Carinii Pneumonia"
 "Increases in CD4 T Lymphocytes with Intermittent Courses of
 Interleukin-2 in Patients with Human Immunodeficiency Virus
 Infection"
 "HIV Counseling and Testing -- United States, 1993"
 "Mechanism of Inhibition of HIV-1 Reverse Transcriptase by
 Nonnucleoside Inhibitors"
 "Changes in Taste Associated with Intravenous Administration
 of Pentamidine"
 "Italian Surgeon Gets AIDS Virus from Scalpel Cut"
 "The AIDS Knowledge Base: A Textbook on HIV Disease from the
 University of California, San Francisco, and the San Francisco
 General Hospital"
 "Self-Insemination May Carry Risk of HIV Infection"
 "Primary Prevention of Cryptococcal Meningitis by Fluconazole
 in HIV-Infected Patients"
 "Storing One's Own Blood for Surgery Strains Medical
 Resources, Study Says"
 "HIV in the Elderly: Not Just from Transfusion"
 "AIDS Clinical Trials: Why They Have Recruiting Problems"
 "Preventing AIDS: Theories and Methods of Behavioral
 Interventions"
 "HIV-Associated Histoplasmosis with Pulmonary Manifestations"
 "Intestinal Mycobacteria in African AIDS Patients"
 "Heart Muscle Disease Related to HIV Infection: Prognostic
 Implications"
 
*********************************************************************

 "India to Become AIDS Epicentre, Conference Told"
 Reuters (03/04/95)

 In five years, India will be the region most affected by AIDS, an
Australian population conference was told on Saturday. India
will overtake Africa as the "epicentre of AIDS" and will probably
have more HIV-infected people than the rest of the world
combined, said Roger Short, a Monash University biology
professor, speaking at the meeting of Australians for an
Ecologically Sustainable Population. Short also said that during
the next 30 years, AIDS will rapidly spread into Asian countries,
especially India. The disease, he added, will have little impact
on the world's population levels. The National AIDS Control
Organization estimates that 1.62 million of India's 850 million
citizens are infected with HIV--up 60 percent from 1993.


 "Treatment of Cytomegalovirus Retinitis With an Intraocular
 Sustained-Release Ganciclovir Implant: a Randomized Controlled
 Clinical Trial"
 J.A.M.A. (03/01/95) Vol. 267, No. 9, P. 682e

 In a randomized controlled clinical trial of the safety and
efficacy of a ganciclovir implant, AIDS patients with newly
diagnosed cytomegalovirus (CMV) retinitis were either treated
immediately with the implant or deferred treatment. Of the 26
patients (30 eyes), the average time to progression of retinitis
was 15 days in the deferred treatment group--compared to 226 days
in the immediate treatment group. A total of 39 primary implants
and 12 exchange implants were placed in immediate-treatment eyes,
deferred-treatment eyes, or contralateral eyes that developed CMV
retinitis. In 34 of 39 eyes, final visual acuity was at least
20/25. The risk of developing CMV retinitis in the other eye was
50 percent after six months. Eight patients developed
biopsy-proven visceral CMV disease. The researchers concluded
that the ganciclovir implant is effective for the treatment of
CMV retinitis. Patients with unilateral CMV retinitis, who are
treated with the implant, will likely develop the disease in the
other eye, and some patients will develop visceral CMV disease,
the study concluded.


 "Gene Therapy and Immune Restoration for HIV Disease"
 Lancet (02/18/95) Vol. 345, No. 8947, P. 427
 Bridges, Sandra H.; Sarver, Nava

 Recent studies have begun to explore innovative strategies that
can target the viral, immunological, and cellular components of
HIV disease. Current studies of HIV gene therapy involve gene
transfer into mature CD4 T cells. Efforts, however, are being
made to deliver antiviral genes to pluripotent hematopoietic stem
cells to guarantee a renewable supply of HIV-protected cells for
the life of the patient. Immune restoration strategies deal with
the transfer of various cell populations to HIV-positive people
with the purpose of restoring immune function. It is generally
agreed that restoring immune cells is more likely to have a
therapeutic effect if the cells are altered to resist HIV
infection. Nucleic acid-based therapeutic vaccines involve
direct delivery of HIV genes into the patient's tissue to imitate
natural infection, and thus, enhance immune responses against
HIV. The combined use of gene therapy, adoptive immune therapy,
and nucleic acid-based immune enhancement represents a
comprehensive treatment regimen that focuses on the key elements
of HIV disease--the virus and the immune system.


 "Debugging Blood"
 Science News (02/11/95) Vol. 147, No. 6, P. 92
 Adler, Tina

 All U.S. blood banks must screen donations for syphilis,
hepatitis B and C, two types of HIV, two types of human T cell
leukemia virus, and other infectious agents. However, most
HIV-tainted blood that reaches transfusion recipients comes from
recently infected people who have not yet developed antibodies to
HIV. Although HIV researchers have developed tests that detect
the virus earlier in infection, the more sensitive screens may
not prove cost-effective if widely used, said an advisory panel
to the National Institutes of Health last month. The panel also
recommended that blood banks stop doing a test that measures the
activity of the enzyme alanine aminotransferase (ALT) in the
blood. ALT enters the bloodstream in response to liver damage,
such as that caused by hepatitis. Other factors, however, such
as heavy alcohol consumption and obesity, that do not make people
unsuitable donors may also increase ALT activity. Each year,
blood banks discard about 200,000 units and turn away 150,000
potential donors because of elevated ALT readings. The hepatitis
B core antibody (anti-HBc) tests--developed to detect non-A, non
B hepatitis virus--was found to indirectly identify HIV-tainted
blood that would otherwise go undetected. The panel concluded
these detections compensate for the test's high false positive
rate.


 "Adverse Cutaneous Reactions to Trimethoprim-Sulfamethoxazole in
 Patients with the Acquired Immunodeficiency Syndrome and
 Pneumocystis Carinii Pneumonia"
 J.A.M.A (03/01/95) Vol. 273, No. 9, P. 682b

 In a retrospective study, researchers assessed the value of
clinical and laboratory parameters for predicting
trimethoprim-sulfamethoxazole-induced skin reactions and the
effects of continued therapy in AIDS patients. The reasons why
AIDS patients are predisposed to cutaneous drug reactions are
poorly understood. Of the 38 patients treated with
trimethoprim-sulfamethoxazole, 18 developed cutaneous reactions
in an average of 11 days. Such treatment was continued in 19 of
the 20 patients who did not develop skin reactions. No clinical
or laboratory parameters were found to be predictive of
trimethoprim-sulfamethoxazole-induced cutaneous reactions. By
treating through hypersensitivity, 67 percent of the patients,
who otherwise might have had to stop therapy with
trimethoprim-sulfamethoxazole, were able to continue treatment.


 "Increases in CD4 T Lymphocytes with Intermittent Courses of
 Interleukin-2 in Patients with Human Immunodeficiency Virus
 Infection"
 N.E.J.M. (03/02/95) Vol. 332, No. 9, P. 567
 Kovacs, Joseph A.; Baseler, Michael; Dewar, Robin J. et al.

 To determine the value of intermittent courses of interleukin-2
for the long-term management of HIV infection, Kovacs et al.
focused on HIV-infected patients with a moderate suppression of
the immune system. Based on previous work, such patients are
more likely to have a response to immunomodulators than patients
with severely impaired immune function. Twenty-five patients
received interleukin-2 for five days every 8 weeks during a
period of seven to 25 months. In addition, all patients received
at least one antiviral agent. Therapy with interleukin-2 was
linked to at least a 50 percent increase in the number of CD4
cells in six of the 10 patients with CD4 counts higher than 200.
For the remaining 15 patients, who had CD4 counts of 200 or less,
interleukin-2 therapy was associated with increased viral
activation, few immunologic improvements, and significant toxic
effects. Kovacs et al. concluded that intermittent interleukin-2
therapy can reverse some of the immunologic abnormalities
associated with HIV infection in patients with CD4 counts above
200.


 HIV Counseling and Testing -- United States, 1993
 MORBIDITY AND MORTALITY WEEKLY REPORT
 Centers for Disease Control and Prevention
 March 10, 1995
 Vol. 44, No. 9

 Counseling and testing (CT) are important components of state
and local human immunodeficiency virus (HIV)-prevention programs
(1). Analysis of national data sources indicates that HIV-antibody
tests are obtained from a variety of testing sites, including
private physicians, hospitals, and outpatient clinics (66.7%), and
publicly funded sites (33.1%) (2). This report uses data from CDC's
1993 Behavioral Risk Factor Surveillance System (BRFSS) to examine
variations in rates of use of private and public HIV CT sites by
state.
 In 1993, a total of 49 states and the District of Columbia
participated in the BRFSS, a state-specific population-based,
random-digit-dialed telephone survey that collects information
monthly from U.S. adults aged greater than or equal to 18 years.
Thirteen questions about HIV/AIDS-related knowledge and attitudes
and HIV-antibody testing history during the preceding year were
asked only to respondents aged less than or equal to 65 years. In
1993, a total of 84,039 persons responded to these questions
(state-specific range: 993 to 3667). The state-specific median
percentage of 82% of eligible respondents completed interviews (3).
Data for each state were weighted by demographic characteristics
and by selection probability; results are representative of persons
aged 18-65 years in each state. Confidence intervals for
percentages and estimated numbers of persons tested were based on
standard errors that accounted for complex survey design (4).
 A median of 25.5% of persons (range: 14.4% [Iowa] to 37.5%
[Alaska]) answered yes to the question: "Except for donating or
giving blood, have you ever had your blood tested for the AIDS
virus infection?" (Table 1). The number (weighted estimate) of
adults who had ever been tested for HIV was highest in California
(6.3 million).
 A median of 9.6% of persons (range: 4.1% [Maine and South
Dakota] to 16.9% [District of Columbia]) reported obtaining
HIV-antibody tests primarily for diagnostic reasons* (Table 1).
Persons categorized as having obtained diagnostic HIV-antibody
tests were identified by one of three responses to the question
"What was the main reason you had your last AIDS blood test?": "to
find out if infected," "because of referral by a doctor or health
department or sex partner," or "for routine checkup**."
 In 43 states and the District of Columbia, at least 50.0%
(median: 60.9%) of respondents had obtained their last diagnostic
test from a private physician, health maintenance organization, or
private outpatient clinic (Table 2). A median of 16.2% of persons
(range: 5.0% [North Dakota] to 37.6% [Mississippi]) had obtained
their last diagnostic test at a publicly funded prevention site
(including health departments; AIDS, sexually transmitted disease
[STD], or tuberculosis clinics; and drug-treatment programs).
 The estimated number of persons who obtained a diagnostic test
at a publicly funded site during the preceding year correlated with
the number of tests reported to CDC's HIV Counseling and Testing
System by publicly funded sites in each state (5) (correlation
coefficient=0.96; p less than 0.01).
 A median of 60.7% of persons who had obtained their most
recent diagnostic HIV-antibody test at a publicly funded site
(range: 30.8% [New Jersey] to 95.7% [Oklahoma]) received counseling
with their test results (Table 2). In comparison, a median of 28.2%
of persons who had obtained their tests from a private site (range:
7.7% [Kentucky] to 77.3% [Oklahoma]) also received counseling. In
most (90%) of the reporting areas, the number of persons who
received counseling with their HIV test results was greater than or
equal to 1.5 times greater for persons tested at publicly funded
sites than those tested at private sites.
Reported by the following BRFSS coordinators: S Jackson, MPA,
Alabama; P Owen, Alaska; B Bender, Arizona; J Senner, PhD,
Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M
Adams, MS, Connecticut; F Breukelman, Delaware; C Mitchell,
District of Columbia; D McTague, MS, Florida; E Pledger, MPA,
Georgia; F Newfield, MPH, Hawaii; C Johnson, MPH, Idaho; B Steiner,
MS, Illinois; R Guest, MPH, Indiana; P Busick, Iowa; M Perry,
Kansas; K Bramblett, Kentucky; D Hargrove-Roberson, MSW, Louisiana;
D Maines, Maine; A Weinstein, MA, Maryland; R Lederman, MPH,
Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; E
Jones, MS, Mississippi; J Jackson-Thompson, PhD, Missouri; P Smith,
Montana; S Huffman, Nebraska; E DeJan, Nevada; K Zaso, MPH, New
Hampshire; G Boeselager, MS, New Jersey; P Jaramillo, MPA, New
Mexico; C Maylahn, MPH, New York; G Lengerich, MD, North Carolina;
D Young, MS, North Dakota; E Capwell, PhD, Ohio; N Hann, MPH,
Oklahoma; J Grant-Worley, MS, Oregon; J Romano, MPH, Pennsylvania;
J Hesser, PhD, Rhode Island; M Lane, MPH, South Carolina; B Miller,
South Dakota; D Ridings, Tennessee; R Diamond, MPH, Texas; R Giles,
Utah; R McIntyre, PhD, Vermont; S Carswell, MA, Virginia; K Holm,
MPH, Washington; F King, West Virginia; E Cautley, MS, Wisconsin.
Behavioral and Prevention Research Br, Div of Sexually Transmitted
Diseases and HIV Prevention, National Center for Prevention Svcs;
Behavioral Risk Factor Surveillance Br, Office of Surveillance and
Analysis, National Center for Chronic Disease Prevention and Health
Promotion, CDC.
Editorial Note: The findings from the 1993 BRFSS document a high
degree of state-specific variability in self-reported HIV-antibody
tests in the United States. This variability may reflect
state-specific differences in such factors as the prevalence of HIV
infection and HIV testing in high-risk groups, the presence and
impact of HIV-prevention programs, and age distribution. The BRFSS
estimates of the number of persons last tested for voluntary or
diagnostic reasons at a publicly funded clinic correlated highly
with estimates from CDC's HIV Counseling and Testing System, and
the median percentage of respondents ever tested for HIV (25%) is
consistent with estimates based on CDC's National Health Interview
Survey (22%).
 Health-care visits to seek and obtain HIV tests are important
opportunities to counsel persons about the risk for HIV infection
and methods to reduce such risk (1). The data in this report
indicate that, in most states, approximately threefold more persons
reported having obtained their HIV test from a private provider
than from a public site; however, persons who had obtained their


 

(Continued from last message)
test from a private provider were substantially less likely to have
reported receiving counseling than those who obtained tests at a
public site. This finding underscores the need for physicians and
other health-care providers in private settings to offer HIV
counseling at the time patients receive their HIV test results.
 The findings in this report are subject to at least two
limitations. First, the sample size of persons who reported having
had an HIV-antibody test in individual states did not enable
stratification by other respondent characteristics. For example,
state-specific sample sizes precluded analysis to determine whether
specific high-risk populations that obtained HIV-antibody testing
also received counseling. Second, because the BRFSS is a
telephone-based system, some persons at high risk for HIV infection
most likely were excluded from the survey.
 The BRFSS is a unique source for information about
HIV-antibody testing behaviors of U.S. adults--particularly
patterns of HIV testing outside of public clinics--and can be used
both at the federal and state levels to improve HIV-prevention and
intervention programs. Questions about CT in the 1993 BRFSS were
developed based on input from state health departments; subsequent
BRFSS surveys may incorporate additional HIV-related behavioral
questions.
References
1. Hinman AR. Strategies to prevent HIV infection in the United
States. Am J Public Health 1991;81:1557-9.
2. CDC. HIV counseling and testing services from public and private
providers--United States, 1990. MMWR 1992;41:743,749-52.
3. CDC. 1993 BRFSS quality control report. Atlanta: US Department
of Health and Human Services, Public Health Service, CDC, 1994.
4. Shah BV. Software for Survey Data Analysis (SUDAAN) version 5.30
[Software documentation]. Research Triangle Park, North Carolina:
Research Triangle Institute, 1989.
5. CDC. HIV counseling and testing data system: national profile,
1993. Atlanta: US Department of Health and Human Services, Public
Health Service, CDC, 1994.

* For this study, diagnostic HIV-antibody tests were defined as
those administered primarily to learn infection status rather than
voluntary tests to qualify for insurance, military induction,
immigration, marriage license application, or employment.
** This response was included in "diagnostic" reasons to avoid
excluding respondents who initiated a routine examination to
determine whether they were infected with HIV.

Clarification: Vol. 43, Nos. 51 & 52
 The notice to readers "Recommended Childhood Immunization
Schedule--United States, January 1995" (pages 959-960) stated that
infants born to hepatitis B surface antigen (HBsAg)-positive
mothers should receive immunoprophylaxis with 0.5 mL of hepatitis
B immune globulin (HBIG) and 0.5 mL of hepatitis B vaccine
administered at separate sites. Hepatitis B vaccines licensed in
the United States are produced by Merck and Co., Inc. (Rahway, New
Jersey), and SmithKline Beecham (Philadelphia) and are available in
various concentrations. The recommended dose of hepatitis B vaccine
for infants varies by manufacturer and HBsAg status of the mother
(Table 1). Merck and Co., Inc., recommends 2.5 ug of Recombivax HB
(registered) for infants of HBsAg-negative mothers and 5.0 ug for
infants of HBsAg-positive mothers; SmithKline Beecham recommends 10
ug of Engerix-B (registered) regardless of the mother's HBsAg
status. Providers should know the HBsAg status of an infant's
mother and consult the product package insert for the recommended
vaccine dose.
 Providers also should be aware that the Food and Drug
Administration recently lowered the age-appropriate dose of
Engerix-B (registered) from 20 ug to 10 ug for adolescents 11-19
years of age (Table 1) (1).
Reference
1. Smithkline Beecham Pharmaceuticals. Brief summary of prescribing
information: Engerix-B (registered) [Package insert]. Philadelphia:
Smithkline Beecham Pharmaceuticals, 1995.

Addendum: Vol. 44, No. 8
 In the article, "Exposure of Passengers and Flight Crew to
Mycobacterium tuberculosis on Commercial Aircraft, 1992-1995," the
following names should be added to the credits ("reported by") on
the sixth line on page 139: A Ignacio, MD, D Morishige, RL Vogt,
MD, State Epidemiologist, Communicable Disease Div, Hawaii Dept of
Health.

Errata: Vol. 44, No. 8
 In the article, "Exposure of Passengers and Flight Crew to
Mycobacterium tuberculosis on Commercial Aircraft, 1992-1995," on
page 138 in the first sentence under investigation 3, the length of
flight is incorrect. The sentence should read, "In March 1993, a
foreign-born passenger with pulmonary TB traveled on a 4 1/2-hour
flight from Mexico to San Francisco."
 In the article, "Use of Safety Belts--Madrid, Spain, 1994,"
the first sentence on page 151 should read, "Of 1063 phone numbers
called to identify eligible households, 294 (27.7%) could not be
contacted (no one answered or the line was busy), and 185 were
excluded (because the phone number was commercial, no one aged
greater than or equal to 18 years was in the home at the time of
the call, or respondents never traveled by vehicle)."


 "Mechanism of Inhibition of HIV-1 Reverse Transcriptase by
 Nonnucleoside Inhibitors"
 Science (02/17/95) Vol. 267, No. 5200, P. 988
 Spence, Rebecca A.; Kati, Warren M.; Anderson, Karen S. et al.

 Spence et al. studied the mechanism of inhibition of HIV-1
reverse transcriptase by three nonnucleoside inhibitors.
Nevirapine, O-TIBO, and CI-TIBO each bind to a hydrophobic pocket
in the enzyme-DNA complex near the active site catalytic
residues. The researchers used pre-steady-state kinetic analysis
to determine the mechanism of inhibition by these noncompetitive
inhibitors. Analysis of the pre-steady-state burst of DNA
polymerization showed that the inhibitors blocked the chemical
reaction, but did not interfere with nucleotide binding or the
nucleotide-induced conformational change. In the presence of
saturating concentrations of the inhibitors, however, the
nucleoside triphosphate bound tightly but nonproductively. The
findings suggest that an inhibitor that combines the
functionalities of a nonnucleoside inhibitor and a nucleotide
analog could bind very tightly and specifically to reverse
transcriptase and could be very useful in the treatment of AIDS.


 "Changes in Taste Associated with Intravenous Administration
 of Pentamidine"
 Glover, Jennifer; Dibble, Suzanne; Miaskowski, Christine

 In an attempt to describe the incidence of taste changes
associated with intravenous pentamidine isethionate (IV PENT)
treatment and to determine the factors that affect the taste
changes, Glover et al. studied 18 adult males with AIDS who were
receiving outpatient treatment for Pneumocystis carinii pneumonia
(PCP) with IV PENT. All of the participants reported an
unpleasant taste after treatment. While 89 percent described the
taste as metallic, 67 percent experienced a bitter taste. The
participants said that factors such as sweet foods and drinks,
juice, and chocolate improved the unpleasant taste. The items
most frequently cited as making the taste worse were milk and tap
water. The study suggests that taste changes associated with IV
PENT occur and produce accompanying decreases in food intake and
appetite. Healthcare providers caring for patients receiving IV
PENT should assess for alterations in taste and inform patients
of them, as well as the concomitant decrease in appetite.


 "Italian Surgeon Gets AIDS Virus from Scalpel Cut"
 Reuters (03/10/95)
 Holmes, Paul

 While operating on an HIV-infected patient, an Italian surgeon
contracted the virus--representing the first documented case of
transmission under such circumstances, said researcher Dr.
Giuseppe Ippolito on Friday. Ippolito is the head of a team at
Spallanzani Hospital in Rome that has conducted one of only two
major studies on the occupational risk of AIDS among health care
workers. Ippolito said the accident took place in a hospital
last year when the scalpel cut through the surgeon's glove. The
surgeon was immediately tested for HIV. The results were
negative, but a follow-up test was positive. "We excluded all
other means of transmission," Ippolito said. In Italy, surgical
patients are not routinely tested for HIV, and can only be
tested, with their consent, when a risk is suspected.


 "The AIDS Knowledge Base: A Textbook on HIV Disease from the
 University of California, San Francisco, and the San Francisco
 General Hospital"
 N.E.J.M. (03/02/95) Vol. 332, No. 9, P.617
 Klein, Robert S.

 "The AIDS Knowledge Base," the work of 102 contributing authors,
focuses on AIDS as it is presented and managed in the United
States. It is intended to be relevant to all geographic regions
for a wide range of health care professionals and motivated
nonprofessionals. The book's 11 sections address the
pathogenesis and management of HIV infection, as well as legal,
economic, and ethical issues. Because many of the authors are
from San Francisco, however, there is a tendency to base general
statements on experience with middle class men. Still,
information that is relevant to all persons affected by AIDS is
usually included. Some particularly comprehensive chapters are
those on the methods of testing for HIV antibody or antigen and
on rochalimaea, and the section on the pulmonary aspects of AIDS.


 "Self-Insemination May Carry Risk of HIV Infection"
 Washington Post (03/15/95) P. A3

 There is a risk of contracting HIV for women who practice
self-insemination with sperm that has not been properly screened
for HIV, a researcher has cautioned. Another researcher,
however, said there have been no reported cases of HIV infection
through artificial insemination since 1986, and said a woman's
risk of becoming infected in such a fashion is "probably remote."
Although the Centers for Disease Control and Prevention (CDC)
recommends that semen donors be tested for HIV, it is not known
how many actually are, said Mary E. Guinan of the CDC's HIV-AIDS
office, writing in the Journal of the American Medical
Association. "Artificial insemination is safe but not completely
so," she wrote. Still, in another study reported in the same
journal, Maria Rosario G. Araneta found that seven of 199 women
artificially inseminated with semen from five HIV-infected men
between 1981 and 1985 tested HIV-positive. The test for HIV
antibody became available in 1985, and no cases of infection
through artificial insemination have been reported since then,
said Araneta, an epidemiologist with the Naval Health Research
Center in San Diego.


 "Primary Prevention of Cryptococcal Meningitis by Fluconazole
 in HIV-Infected Patients"
 Lancet (03/04/95) Vol. 345, No. 8949, P. 548
 Quagliarello, Vincent J.; Viscoli, Catherine; Horwitz, Ralph I.

 Quagliarello et al.'s study of the use of oral fluconazole
provides evidence for the use of the drug in preventing a first
episode of cryptococcal meningitis in HIV-infected people.
During the six months before lumbar puncture--a method of
specific diagnosis--two of the 18 subjects with cryptococcal
meningitis and 26 of the 72 controls were exposed to fluconazole.
This finding indicates a 92 percent protective efficacy for
fluconazole exposure. The researchers concluded that fluconazole
decreases the risk of a first episode of cryptococcal meningitis
in people with CD4 counts less than 250. Because the patients
were exposed to fluconazole for an average of 30 days, it is
possible that a significant protective effect could be achieved
with less than daily use.


 "Storing One's Own Blood for Surgery Strains Medical
 Resources, Study Says"
 Wall Street Journal (03/16/95) P. B6
 Rundle, Rhonda L.

 The increasingly popular practice of autologous donation--or
banking one's own blood for possible use during surgery--is
expensive, strains medical resources, and offers little benefit
to society, a new study concludes. The study, published in this
week's New England Journal of Medicine, analyzes a medical
procedure that many blood banks and physicians began to promote
in the early 1980s after stories spread about people who became
infected with HIV through a blood transfusion. In light of the
improvements in the safety of the blood supply over the past
decade, however, autologous blood may be a poor use of scarce
medical resources, according to Dr. Jeff Etchason, the study's
lead author, a staff physician at the West Los Angeles Veterans
Affairs Medical Center. An editorial that accompanies the study,
however, says that "the peace of mind that comes from having
control over the risk of AIDS and other potentially harmful
effects of transfusion is immeasurable." The study concludes
that the incremental cost-effectiveness of autologous blood,
expressed as dollars per quality-adjusted year of life saved,
ranged from $235,000 to more than $23 million.


 "HIV in the Elderly: Not Just from Transfusion"
 AIDS Clinical Care (03/95) Vol. 7, No. 3, P. 25

 Two small studies add to the data known about the small, but
growing population of HIV-infected people who are aged 60 or
older. The first study analyzed the charts of 27 men and 5 women
ages 60 to 83 at an inner-city Atlanta hospital. In 15 of the 20
cases where the source was known, HIV was transmitted through sex
or injection drug use. Transfusion was the cause in only three
cases. Diagnosis was frequently delayed because the patients
were not considered to be at risk for HIV. The second study
looked at serum samples taken from 170 elderly patients who died
between 1992 and 1993 at Harlem Hospital in New York. The
researchers found evidence of HIV infection in 6 percent of the
men and 9 percent of the women. Once again, most or all of the
cases were unsuspected, and many of the patients had no known
risk factors. Clinicians should be aware of the potential for
HIV in the elderly and should take a sexual history regardless of
age. There is evidence that older sexually active
people--including those with HIV risk factors--have much lower
rates of condom use than younger people.


 "AIDS Clinical Trials: Why They Have Recruiting Problems"
 AIDS Treatment News (02/17/95) No. 217, P. 1
 Mirken, Bruce

 AIDS clinical trials often have difficulty enrolling the number
of volunteers needed. "The majority of our trials take a lot
longer than anybody expected to enroll. My guess is that this is
what's happening across the country." said Ronald Mitsuyasu,
director of the University of California at Los Angeles' Center
for Clinical AIDS Research and Education. Obstacles to
enrollment in AIDS trials can be divided into two categories: the
publicity or outreach efforts used to recruit volunteers, and the
design of the trials themselves. One problem with publicity is
that drug companies are often reluctant to release data on a
drug, which makes it difficult for recruiters to give potential
volunteers the data they need to feel safe in the study. Another
is the lack of clear guidance from the Food and Drug
Administration on what publicity materials should or should not
say--which can lead some trial sponsors to err on the side of
caution by not saying enough. People, however, will not be
attracted to a trial whose design is inherently unappealing to
patients or whose inclusion/exclusion of criteria keeps out to
many possible volunteers. Mitsuyasu noted that "patients are
almost burnt out, and maybe somewhat pessimistic about what
trials can do for them."


 "Preventing AIDS: Theories and Methods of Behavioral
 Interventions"
 N.E.J.M. (03/02/95) Vol. 332, No. 9, P.617
 Fleming, Patricia

 "Preventing AIDS: Theories and Methods of Behavioral
Interventions," edited by Ralph J. DiClemente and John L.
Peterson, is a series of essays detailing behavioral
interventions and assessing current research on preventing HIV
infection among populations including runaways, heterosexual men
and women, and adolescents. The first six chapters describe
behavioral-science research methods. These chapters are based on
the health-beliefs model, in which change in a person's behavior
occurs only if that person perceives a risk and believes that the
outcome can be affected through behavior change. In the nine
chapters about research on HIV prevention in populations at high
risk, the authors accent what is needed and recommend methods to
evaluate the outcomes. The editors call for the promotion of
self-management to reduce risk at the individual level, and the
promotion of sustained changes in social norms through
community-level interventions.


 "HIV-Associated Histoplasmosis with Pulmonary Manifestations"
 J.A.M.A. (03/08/95) Vol. 273, No. 10, P. 758k

 Wockel et al. present a case in which a 35-year-old man
experienced a general deterioration of health--characterized by
symptoms including weight loss, fever, and abdominal pain. The
man learned in 1991 that he was infected with HIV. He was given
tuberculostatic drugs because miliary tuberculosis was suspected.
As his condition worsened, however, he was thought to have
Pneumocystis pneumonia, and high doses of co-trimoxazole were
administered. Acid-Schiff reaction and Grocott staining revealed
several histoplasma in alveolar macrophages and connective
tissue. Therapy was shifted to itraconazole, but changed to
liposomal amphotericin B two weeks later because of renewed
fever. After six weeks of treatment, the patient was
symptom-free and the radiological changes had largely regressed.
Itraconazole therapy is being continued to prevent recurrence.


 "Intestinal Mycobacteria in African AIDS Patients"
 Lancet (03/04/95) Vol. 345, No. 8949, P. 585
 Pankhurst, C.L.; Luo, N.; Kelly, P. et al.

 Infection with both HIV and Mycobacterium tuberculosis has had a
significant impact on the epidemiology of tuberculosis (TB) in
sub-Saharan Africa. Pankhurst et al. conducted a cross-sectional
study of the prevalence of mycobacteria in 120 fecal samples
taken from 69 patients with HIV-related diarrhea attending the
University Teaching Hospital in Lusaka. Fecal specimens from
seven of the 69 patients grew mycobacteria--two had Mycobacterium
avium complex (MAC), four had M. tuberculosis, and one had M.
flavescens. In a parallel study, the researchers studied fecal
specimens from HIV-infected patients in London. Similar rates of
recovery of mycobacteria were found, with seven of the isolates
being MAC and one M. tuberculosis. One half of the
stool-positive cases developed disseminated disease during the
6-12 months of follow-up. Pankhurst et al. concluded that M.
tuberculosis and MAC are found in the gut of 10 percent of
African patients with HIV-related diarrhea. There is, however,
little evidence of the small intestinal mycobacterial disease
found in AIDS patients in industrialized countries. Despite high
rates of infection in people with AIDS, M. tuberculosis is not a
significant contributor.


 "Heart Muscle Disease Related to HIV Infection: Prognostic
 Implications"
 J.A.M.A. (03/08/95) Vol. 273, No. 10, P. 758h

 To determine the natural course of heart muscle disease in
HIV-infected patients, Currie et al. studied HIV-infected adults
to detect myocardial dysfunction and time to death. Forty-four
of the 296 subjects were diagnosed with cardiac dysfunction. In
contrast to other forms of cardiac dysfunction, dilated
cardiomyopathy was strongly associated with a CD4 cell count less
than 100. Compared to those with normal hearts, patients with
dilated cardiomyopathy had significantly reduced survival rates.
While 101 days was the average survival time for those patients
with cardiomyopathy, those with normal hearts and a CD4 cell


 

(Continued from last message)
count less than 20 lived 472 days. There were no significant
differences in survival for participants with borderline left or
isolated right ventricular dysfunction. Even with the reduced
cell count with which dilated cardiomyopathy is associated, the
prognosis for HIV-infected patients with dilated cardiomyopathy
is poor. Isolated right and borderline left ventricular
dysfunction, however, are not linked to diminished CD4 counts and
do not carry adverse negative prognostic implications.



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End of HICNet Medical News Digest V08 Issue #13
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