Subject: Nutrition; Immunizations; Pentamidine Date: Dec 2 1987 (712 lines) &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& TREATMENT ISSUES -- The GMHC Newsletter of Experimental AIDS Therapies &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& Volume 1 Number 1 December 2, 1987 FROM THE EDITOR This is the first issue of Treatment Issues, GMHC's newsletter devoted exclusively to experimental and alternative AIDS therapies. Our first issue appears at a time when people are frustrated about the seemingly lethargic approach to new research. One of the most frequently expressed concerns is that drugs that have shown promise are being ignored. Rumors of new effective treat- ments are prevalent but much anecdotal information escapes pro- fessional scrutiny. GMHC hopes to challenge this situation head-on by disseminating reliable information on experimental treatments. Our primary audience will be PWAs; however, in order to strike a balance between scientifically trained readers and laypeople, articles will include footnotes for those who wish to do further research. It is important for readers to understand that, by featuring news about an alternative or experimental treatment, GMHC is never recommending it. Each patient should always discuss any new treatment with his/her personal physician. We encourage readers to write us with their comments. IN THIS ISSUE Nutrition and AIDS Immunizations for PWAs Pentamidine Update Immunizations For PWAs Fall is the time of year when recommendations are made for elderly people and people with chronic diseases to receive influenza and pneumococcal vaccines. Pneumococcal pneumonia and influenza can be devastating illnesses to PWAs but the question of whether or not PWAs should receive routine vaccinations remains unanswered. There are serious considerations in vac- cinating a person with AIDS: whether the vaccine, by stimulating the immune system, may actually accelerate the course of HIV infection; and whether a person with AIDS could respond immuno- logically to a vaccine at all (i.e., mount an antibody response). Both of these questions have been addressed, and the available evidence is presented here. Pneumococcal Vaccine: In a study conducted at the University of Colorado, 32 HIV- infected individuals were vaccinated with pneumococcal vaccine. The AIDS/ARC patients did exhibit an initial rise in antibody levels, indicating that the vaccine "took", but these levels dropped to baseline within 40 weeks.(1) Other studies have found suboptimal antibody responses to pneumococccal vaccine in HIV- infected patients (2,3). These limited studies do not appear to have accelerated the HIV infection, as no adverse effects or clinical deterioration have been reported (4,5). In the Multicenter AIDS Cohort Study (MACS) at the University of Pittsburgh, pneumococcal vaccine is being tested in a high-risk group of gay males without untoward reactions. The final report is not yet in. Influenza Vaccine: Similar findings have been reported with influenza vaccine. Some investigators (4) have found good antibody responses but others (3) have found suboptimal responses. In the MACS study, good antibody response was noted. As to the safety issue, adverse effects or clinical deterioration have not been seen with influenza vaccine (4,5,6). The MACS study confirms these find- ings. The experience gained to date has prompted the World Health Organization to issue guidelines on the immunization of HIV- infected individuals. For children, the WHO recommends continued administration of standard vaccines, with the exception that inactivated polio vaccine (IPV) be substituted for the oral polio vaccine (OPV). For HIV-infected adults, WHO makes no specific recommendations (7) but state that "data from prospective human studies have not shown any adverse effects of immunization on immune function or progression of symptoms among HIV-infected recipients of vaccines." Dr. John LaMontagne, the Influenza Program Officer of NIAID (The National Institute for Allergy and Infectious Diseases) agrees that vaccines can be given safely. He states, "It appears from the studies done by the NIAID, primarily by the MACS inves- tigators, that vaccination is useful...It would appear that because antibody responses are not as strong in HIV-infected per- sons, a decrease in vaccine efficacy might be a logical conse- quence."(8) Thus, it seems that the safety issue has been adequately studied to permit the use of vaccines in the setting of AIDS. Whether the antibody response is sufficient as to result in a lower risk of developing influenza or pneumococcal pneumonia has not been resolved, but all studies have shown at least some increase in antibody levels. Hopefully, this increase would be protective for a significant period of time. While it is generally recommended that susceptible individu- als get pneumococcal vaccine only once in their lifetime, these data suggest that PWAs receive it each winter. Influenza vaccine is always given yearly. Vaccinations for pneumococcal pneumonia and influenza deserve serious consideration from each PWA and his/her physi- cian. Pentamidine Update On October 4, medical professionals and researchers gathered at the New York Hilton to attend a symposium sponsored by Sloan- Kettering Cancer Center. The topic of the meeting was aerosol Pentamidine inhalation as therapy for PCP. Traditionally, this drug has been administered intravenously, but a major disadvantage of this method is that, when injected into the bloodstream or a muscle, Pentamidine disperses throughout the body and it can cause toxic reactions in various organs. The four papers presented helped to flesh out the current body of knowledge about this drug. When compared to other published results, these data yield some interesting, albeit preliminary generalizations. Presentations began on an optimistic note, with Dr. Hetty Waskin, of the CDC venturing her opinion that the response rate of AIDS patients experiencing their first bout of PCP would be 80-90% when treated with aerosol Pentamidine. Results from two pilot studies suggest that aerosol Pentami- dine may have a slight edge on intravenous Pentamidine in terms of efficacy. Dr. Bruce Montgomery presented data from a study at San Francisco General whose goal was to maximize delivery of the aerosolized drug to the lower lung, thereby reducing toxicity in the bronchial passage. 13 of the 15 patients (87%) receiving 4mg/kg of aerosol Pentamidine achieved successful results. None of the 15 experienced major adverse reactions, compared to 13% of patients receiving Bactrim in a tandem study (9). Larger trials, in which the same dosage was given intravenously yielded the fol- lowing recovery percentages: at Kaiser Medical Center, 61% of 36 patients recovered (10); at New York Medical College, this figure was 68% of 31 patients (11). At UCSF, Dr. John Conte monitored a pilot study comparing the standard dose (4mg/kg) of aerosol Pen- tamidine with a reduced dose (3mg/kg) of intravenous Pentamidine. 69% of the patients in the first group recovered, compared with 89% in the second (12). Although the number of participants receiving the reduced dosage was low (9 patients), the 89% suc- cess rate seems promising for intravenous Pentamidine when one considers that the less of the drug will induce lower toxicity and is more economical. These studies seem to suggest that both, aerosol and reduced dose intravenous Pentamidine are non-toxic, effective treatment for mild to moderate cases of PCP. The potential for a combina- tion of IV-administered and inhaled Pentamidine to effectively treat severe PCP needs to be examined. Occurrence of major adverse reactions is one area where aerosol Pentamidine distinguishes itself dramatically from intravenous Pentamidine. In studies at Kaiser, and N.Y. Medical Center, roughly one third of participants receiving intravenous Pentamidine at the normal dosage experienced side effects includ- ing hypotension, hypoglycemia or liver and kidney problems (9,11,13). Interestingly, a smaller percentage (approximately one-fifth) of the patients who received a reduced dose intravenously at UCSF experienced these complications (12). The presence of toxicity-related side effects was minimal in the aerosol trials. Only one such trial (2 of 13 patients at UCSF) reported major adverse reactions (12). This advantage of aerosol Pentamidine can be attributed to efficient delivery of the drug to the area of infection, for which nebulizers can claim credit. Patients should definitely consider the high toxicity associated with intravenous Pentamidine when discussing therapy for acute PCP with their physicians. As the focus switched to preventive use of Pentamidine, (prophylaxis) two papers offered conflicting interpretations con- cerning the drug's ability to ward off subsequent cases of PCP. Avoiding recurrent PCP is a critical issue for PWAs; roughly 60% have progressed to repeat bouts with this often fatal infection. Researcher Ed Bernard has reported the most encouraging data so far: in trials at Sloan Kettering, 172 patients have been receiving aerosol Pentamidine in 60 mg doses (approx. 1mg/kg) weekly for four weeks, then every other week. Only a single episode of PCP has occurred over 5 months therapy (14). This patient has since been treated, has recovered, and is back in the trial. On the other hand, Dr. C. Thomas Boylen is monitoring a much smaller study at USC Medical Center in which 31% of 25 par- ticipants have developed recurrent cases of PCP after 24 weeks of inhaling 2mg/kg (about 140 mg) twice a month (15). In spite of these lackluster figures, Dr. Boylen stated that he believed that aerosol Pentamidine would be effective prophylactically when used as an adjunct to some other drug. Given the much larger size of the Sloan Kettering trial, these results can be considered more authoritative. An earlier prophylactic study involving fewer patients receiving 4mg/kg of intravenous Pentamidine was conducted at the Cleveland Clinic Foundation, where 1/8 patients who adhered to monthly therapy developed recurrent PCP. In another study, 1/18 receiving bimonthly therapy had a relapse (16,13). Although these figures are not discouraging, aerosol Pentamidine emerges as the more effective therapy of the two for prophylaxis. It also appears probable that aerosol Pentamidine is an attractive alternative prophylactically to Bactrim or Dapsone, two standard treatments that are not well tolerated by signifi- cant percentages of patients with PCP. Dr. Ron Grossman, who spoke last, shared some of his experi- ences in treating PCP since 1981. He called it the "most diffi- cult" opportunistic infection to treat, due to the costly and expensive procedures in use. In HIV positive patients that he has treated, he noted that the recurrence rate is sometimes 80%. Dr. Grossman noted that, from 1981 to 1985, the mortality rate among his patients was running consistently at 50%. In the last 2 years, however, that number has declined appreciably. Dr. Grossman attributes the higher survival rate to better treatments and understanding of PCP. Observing that he has administered weekly doses of 120 mg with no adverse reactions, Dr. Grossman suggested that disap- pointing trial results of aerosol Pentamidine as prophylaxis (e.g. at USC Medical Center) (15) were due to low dosage. To battle the high recurrence rate, he suggests higher doses and more efficient, better supervised administering of the drug. Since effective delivery of Pentamidine is largely dependent on droplet size, it is important to use a high quality nebulizer, which is an instrument that vaporizes the drug in an extremely fine mist for inhalation. The Siemens "green machine" has been surpassed by a device called "Pulmo-Sonic", manufactured by DeVilbiss Co. It delivers much smaller droplets than the Sie- mens. This nebulizer also tends to heat the drug, which may have some effect on the potency. Pulmo-Sonic is available upon prescription in the New York metropolitan area from the following distributors: Metropolitan Respiratory Service (212-904-0770); Prime Care Medical (718-445-8411); Foster Medical (718-746-2100); and Metropolitan Medi-Care Co. (201-433-5720). All suppliers said they accept payment from private insurance companies and Medicaid, although persons qualifying for N.Y. Medicaid may have trouble receiving authorization for payment to Metropolitan Medi-Care, which is in New Jersey, and seems to be the most economical choice. Of special note, Prime Care is offering discount prices for people with no insurance or Medicaid cover- age. Another nebulizer developed by Fison will also produce dro- plets in an effective size without heating the drug, and it should be available soon on a compassionate basis. A larger study of aerosol Pentamidine is being planned by the federally funded AIDS Treatment Evaluation Unit (ATEU) sys- tem. Eligibility requirements will include severe ARC conditions and PWAs who have experienced bouts of PCP. Look for more infor- mation about this study in later issues. Nutrition and AIDS One of the first questions that a person asks after diag- nosis is "What should I be eating? Should I become macrobiotic? Should I give up sugar, caffeine, etc?". As with drug therapies, there are no easy answers to these questions. For different peo- ple, different approaches may be beneficial. The following compendium of recommendations is based on research on nutrition and immunity from reputable medical jour- nals and textbooks. It is essentially a "western medicine" approach to nutrition for PWAs. It is not the final word on nutrition, but it does address such subjects as macrobiotics and high-dose vitamin C. Contrary to claims being made, there are no magic pills or supplements which have been shown by themselves to dramatically improve immunity; however, much can be done nutri- tionally to create an environment which will help promote optimal immune function. The first rule of nutrition (as in life) is "Everything in Moderation." There is no evidence that giving up completely such things as sugar and alcohol is advantageous; Some may feel empowered and benefit psychologically from such extremes, but for most, the perceived deprivation probably does more harm than good. Of course, how one defines "moderation" varies from person to person; generally, nutritionists have no problem with the con- sumption of one alcoholic beverage or one concentrated sweet daily. Despite widespread claims of a so-called "Yeast Syndrome" this has failed to gain acceptance by medical authorities. Pro- ponents of this syndrome contend that yeast infection causes immune suppression which in turn causes more yeast infection and becomes a vicious cycle. They believe that eating refined car- bohydrates and anything made with yeast (e.g., bread) encourages the yeast to grow. These claims have not been adequately proven. Yeast (Candida) infection is a result, not a cause, of immune suppression. Furthermore, there is no evidence that avoiding refined carbohydrates, sweets, or yeast reduces Candida infec- tion. >> CALORIES & PROTEIN: These are lumped together because a deficiency in either or both can have seriously detrimental effects on the immune system.(16) It is essential that immunode- ficient patients receive adequate calories so that weight loss is minimized, especially if diarrhea or fat malabsorption is a prob- lem. Supplements such as Ensure and Sustical are good for the patient who is eating nothing else, because they contain vitamins and minerals in addition to protein and calories. If a patient can swallow vitamin and mineral supplements in pill or liquid form, a better (and cheaper) calorie/protein supplement would be a homemade "protein shake" incorporating whole milk (if tolerated) with a high-quality protein powder and whatever else that improves palatability (such as a banana). This can be sipped on during the day if appetite is a problem. Immunodeficient patients should get PLENTY of protein, and the bulk of it should be ANIMAL protein. Vegetables and grains contain incomplete proteins and have to be expertly combined to be accessible; for this reason, they are not recommended as a primary protein source. Consequently, strict macrobiotic diets are not recommended. Macrobiotic diets, if followed strictly, allow only occasional small amounts of fish. Even if the veget- able protein sources were carefully mixed to improve their overall quality, switching from animal protein to totally veget- able protein requires major adaptation by the body and should not be done abruptly. Being macrobiotic is basically a full-time job, and most PWAs are unable to maintain a consistent high- quality macrobiotic regime. Macrobiotic diets, however, are gen- erally "cleaner", with less chemicals and food additives. There- fore, modified macrobiotic diets, containing animal protein (see "PROTEIN SOURCES" below) are perfectly okay and maybe even desir- able. It should be noted that macrobiotic patients with KS were studied and have failed to show significant immune response or survival time.(17,18) >> PROTEIN SOURCES: Eat generous amounts of fish, chicken, and (occasionally, if desired) LEAN beef. Calves liver on occa- sion is okay. Buy all your meats from a reputable butcher. Because of the pervasive use of chemicals in meat, including antibiotics, hormones and pesticides, it is probably wise to seek out certified "organic" meats. For poultry, this is easy to find: the preferred chicken is Bell & Evans which is raised in a free-range environment without hormones or antibiotics. In New York City, it is available at Jefferson Market, University Place Market (10th & University), and Lobei Brothers (Madison & 82nd) among others. When cutting raw poultry, all utensils and cutting boards coming into contact with the bird must be washed thoroughly with hot soapy water (including your hands). This is because of the risk of contamination with salmonella (thorough cooking will kill salmonella). Do not use a wooden cutting board to cut raw poultry. It is impossible to find certified organic pork. Pigs are often fed recycled garbage which usually contains toxic inks, dyes, and other chemicals. Therefore, the consumption of pork is not recommended. CURED MEATS ARE TO BE AVOIDED (bacon, salami, corned beef, etc.) as they are permeated with immunosuppressive chemicals like nitrates (which is thought to be a cofactor for KS). All meats should be cooked to the "medium" stage (barely pink if at all); NO RAW BEEF OR FISH are to be eaten because of the risk of parasites. Raw egg yolk should not be eaten because of the risk of salmonella; all egg lecithin products (generic AL721) should be certified free of salmonella. Whole-milk dairy products are excellent if well tolerated; including ice cream and yogurt. >> FATS: The immune system is affected by the type of fats consumed. Studies show that the currently recommended high polyunsaturate diet may be damaging to immune function.(19,20) Although not proven, it probably has to do with the poor quality of commercially available vegetable oils which are heated to dangerously high temperatures during the extraction process. The result is high levels of "free radicals" (in lay terms, ranci- dity). Free radicals have a significantly damaging effect on lymphocytes. For this reason, all vegetable fats, including may- onnaise, should be labelled "cold-pressed" or "expeller-pressed." They are generally available at health food stores (HAIN is a good brand) and should be stored in the refrigerator. Avoid com- mercially prepared fried foods; deep frying at home is okay if fresh, cold-pressed oil is used each time. Hydrogenated fats such as vegetable shortening and margarine are to also to be avoided. Use butter (in modest quantities) instead. Recommend- ing butter may seem contrary to what we have learned about fats in the 'Prudent Diet'. Remember, what we are seeking is short- term effects on the immune system. Long-term effects for the cardiovascular system (cholesterol reduction) are of secondary importance here. There has been a recent wealth of information on the effect of dietary fats on prostaglandin production in the body. In sim- ple terms, prostaglandins are involved in many reactions in the body and can affect many types of cells. Some are "good" (anti- inflammatory) and some are "bad" (pro-inflammatory). It has been well demonstrated that prostaglandin synthesis is affected by the types of fat in the diet.(21) "Bad" prostaglandins have a depressive effect on lymphocytes, so a diet designed to increase production of "good" prostaglandins (called "3-series prostaglan- dins") would be of theoretical benefit. Fats found in fish can increase the body's production of "good" prostaglandins and have beneficial effect on immune function.(22) Thus, it may be advis- able to consume fatty fish (salmon, mackerel, sword, tuna) at least three servings per week. Alternatively, fish oil supple- ments are commercially available (though expensive), usually under the name EPA (eicosopentaenoic acid). An appropriate dose would be 2,000 MG of EPA daily (4-5 average capsules). Shaklee is a good brand (see SUPPLEMENTS below). >> FRUITS & VEGETABLES: Plenty of fresh fruits and veget- ables are recommended. They should be scrubbed thoroughly to remove all pesticide residues and microorganisms. Vegetables should be steamed gently to make nutrients more accessible. >> SUPPLEMENTS: Much has been written in the lay press regarding supplementation and the immune system; unfortunately, most of it is not based in fact. Many people, subscribing to the "more is better" school of thought are taking many nutrients in excess. In some cases, these excesses can actually impair immune function. "Ball-park" figures for a prudent daily supplement regimen might include: Vitamins: Vitamin A - 10,000 IU ** Vitamin B1 - 5-20 MG * Vitamin B2 - 5-20 MG * Vitamin B3 - 50-200 MG * Vitamin B5 - 50-200 MG * Folic Acid - 400 MG Vitamin B6 - 5-20 MG * Vitamin D - 500 IU Vitamin C - 250-1,000 MG * Vitamin E - 400 IU * Minerals: Calcium - 800 MG Magnesium - 400 MG * Zinc - 150 MG * * These nutrients are recommended in excess of the U.S. RDA; they are explained below. ** Preferably as Beta-carotene Stick with name-brand supplements: I prefer Shaklee because of its reputation for superior formulation and quality control. About the extra B and C Vitamins and Magnesium: Several studies point out the increased excretion of these vitamins dur- ing stress. Thus, a modest supplement seems appropriate. Pro- ponents of high-dose vitamin C therapy (some use over 30,000 mg daily) have failed to show improvement in their patients. About the extra Zinc: Zinc deficiency has been demonstrated in AIDS and ARC patients (23). In the dose indicated above, zinc has been shown to enhance immune function in normal subjects (24) and people with ARC (25). However, in doses in excess of 300-400 MG, it can actually impair immune function (26). This is one definite example of "more is NOT better". Also, build up to this dose gradually to avoid stomach upset which can sometimes occur. About the extra Vitamin E: By neutralizing harmful sub- stances produced by the pneumocystis organism, Vitamin E may reduce the damage to the lung during and after PCP. About thymus preparations: Several preparations are avail- able on the market which are extracts from animal thymus (usually sheep). There is no evidence whatsoever that they will improve a poorly functioning immune system. It is tempting to speculate that such extracts would contain certain beneficial thymic fac- tors. This has not been demonstrated: moreover, the thymic extracts when swallowed are digested like everything else in the stomach and never reach the bloodstream in their intended form. >> A FINAL NOTE: There are many charlatans out there who are are prepared to sell you (at great expense) prepackaged sup- plements which are purported to have immune enhancing properties. One has recently come to my attention called "Immune Systems Pro- gram". Their supplements cost over $80 per month, have fancy names, and will do nothing special. Don't expect magic pills do undo damage that may have already been done to your immune sys- tem. Nutritionally, this can't be done. What CAN be done is to optimize your nutrient intake so that your immune system has the best chance possible of fighting infection and recovering. In Brief... The AmFAR Directory of Experimental Treatments for AIDS & ARC is being made available at no charge from AmFAR. Any PWA, PWARC or concerned loved one may obtain a copy of this important but highly technical resource from AmFAR. The Directory lists and describes experimental drugs for AIDS. For each drug, it also lists where the drug is being tested and the eligibility require- ments for each study. These descriptions are very technical and may be best understood by physicians. Contact Mitchell Speer, American Foundation for AIDS Research, 40 West 57th Street, Suite 406, New York, NY 10019....New York State has received $8.5 mil- lion of the $30 million recently allocated by Congress for AZT. With these funds, the New York State Department of Health has established the AIDS Drug Assistance Program (ADAP). It is estimated that 1,000 people in New York State may qualify for free AZT if they: 1. live in New York state; 2. are medically and financially eligible; and 3. are not covered by a private insurance policy or Medicaid. To receive more information or to request an application, call 1-800-542-2437. For information on other states' programs, contact the national Retrovir Hotline: 1-800-843-9388 .... A new report from The New England Journal of Medicine has demon- strated the safe and effective treatment of acute episodes of Pneumocystis with a drug called trimetrexate. Since about 50% of patients experience adverse reactions to the two standard thera- pies, trimethoprim/sulfamethoxazole (Bactrim) and pentamidine, this may prove to be an important advance in the treatment of PCP. Trimetrexate is still an investigational drug but it is available to PWAs on a Compassionate Use basis from the NIH. Patients who have failed both Bactrim and Pentamidine (either because of adverse reaction or lack of response) would qualify. Physicians interested in obtaining trimetrexate on this basis should contact Dr. Karen Hielfert at the NIH at 301-496-8210 .... On October 26, Syntex, who manufactures the experimental drug DHPG (Gancyclovir), went to the FDA to try to get it approved for widespread use. FDA denied the request. There were rumors that Syntex, having invested almost two years and millions of dollars, would scrap DHPG. Fortunately, they have not. Company spokesmen said that the drug will still be available on a compassionate use basis. DHPG is the only effective treatment for CMV (cytomegalo- virus) infections. Contact for compassionate use: Dr. William Buhles, 415-855-5875.... New Studies: A new study using Imuthiol (DTC) will be recruiting patients soon. It will be conducted at Downstate Medical Center (Brook- lyn, NY) under the supervision of Dr. Adrian Marcel. She will be recruiting 40-50 patients and will be looking for both AIDS and ARC patients. AIDS patients must have at least 100 T4 cells; ARC patients must have under 500 T4 cells and be symptomatic (e.g., lymphadenopathy, thrush, etc.). The study will have a placebo design and will continue for 6 months. People will be allowed to take AZT and drugs for PCP prophylaxis. They will be evaluated at Downstate Medical Center monthly, involving a physical examina- tion, blood tests and skin tests. Physicians may contact Dr. Mar- cel at 718-270-1849 with referrals. DTC is a drug which influ- ences the maturation of T-cells. In preliminary studies, it has caused increases in T4 cells in people with ARC. We will be pub- lishing an issue on DTC in the near future.... Other Resources American Foundation for AIDS Research (AMFAR) has compiled a manual of basic data, updated regularly, about AIDS and experi- mental treatments, entitled "Background Information for People With AIDS, ARC and Related Illnesses -- and those who care about them." Write to AMFAR at 40 West 57th St., New York, N.Y. 10019, or call (212) 333-3118. "AIDS Treatment News" is a short, biweekly report which chronicles current developments in experimental and alternative treatments and deals with public policy issues. Contact John S. James at P.O. Box 411256, San Francisco,CA 94141 or call (415) 282-0110. "PWA Coalition Newsline", published "by and for people with AIDS and AIDS Related Conditions," is a grass-roots news magazine that appears monthly. The publication reports news developments dealing with the health crisis as well as alternative treatments. Editorials and literary contributions add another interesting dimension to this excellent source of information. Write PWA Coalition Inc., 263A West 19th St., Room 125, New York, N.Y. 10011, or call (212) 627-1810. Ask about their other publica- tion, "Surviving and Thriving with AIDS". The Universal Fellowship of Metropolitan Community Churches publishes a monthly newsletter called "Alert", covering AIDS related legislation, education, research and treatment. Write to Rev. Steve Pieters, UFMCC, 5300 Santa Monica Blvd., Suite 304, Los Angeles, CA 90029. Treatment Issues is published ten times yearly by GMHC, Inc. Permission is granted for non-commercial reproduction. Subscription lists are kept confidential. Editor: Barry Gingell, M.D. Associate Editor: Kevin Armington To be included or removed from the mailing list, write to: GMHC, Inc., Department of Medical Information, 132 West 24th Street, Box 274, New York, NY 10011. Footnotes: 1 Janoff EN et al. Effect of Human Immunodeficiency Virus (HIV) Infection on the Longitudinal, Isotype-Specific Humoral Response to Pneumococcal Vaccine. 27th Interscience Congress on Antimi- crobial Agents and Chemotherapy, New York, 1987, #893. 2 Douglas, JM, et al. Response to pneumococcal and influenza vaccines in gay men with asymptomatic HTLV-III infection and with AIDS. 26th Interscience Congress on Antimicrobial Agents and Chemotherapy, New Orleans, 1986. 3 Ragni, MV et al. Antibody responses to immunization of patients with hemophilia with and without evidence of human immu- nodeficiency virus infection. J. Lab Clin. Med. 109: 545-9, 1987. 4 Huang K et al. Antibody response after influenza and pneumo- coccal immunization in HIV infected homosexual men. JAMA 157: 2047-50, 1987. 5 Rhoads JL et al. Response to vaccination in HIV seropositive subjects. Third International Conference on AIDS. Washington, June, 1987, WP.110. 6 Nelson KE. The influence of HIV infection on antibody responses to influenza vaccines. Third International Conference on AIDS. Washington, June, 1987, WP.116. 7 von Reyn CF et al. Human Immunodeficiency Virus Infection and Routine Childhood Immunisation. Lancet, September 9, 1987, 669- 72. 8 John LaMontagne, personal communication. 9 Montgomery AB et al. Aerosolized Pentamidine as sole therapy for Pneumocystis carinii. 27th Interscience Conference on Antim- icrobial Agents and Chemotherapy, New York, 1987, #947. 10 Cowan R et al. TMP-SMX vs. Pentamidine for Pneumocystis: Prospective, Non-Crossover Study. 27th Interscience Conference on Antimicrobial Agents and Chemotherapy, New York, 1987, #942. 11 Klein NC et al. Prospective Randomized Treatment for Pneumo- cystis carinii Pneumonia in AIDS patients. Second International Conference on AIDS, Paris, 1986, #293. 12 Conte JE et al. Inhaled Pentamidine or Reduced Dosage of Intravenous Pentamidine for Treatment of PCP in AIDS patients. 27th Interscience Conference on Antimicrobial Agents and Chemoth- erapy, New York, 1987, #946. 13 Johnson ES et al. Secondary Prophylaxis of PCP in AIDS Patients Using Bi-Monthly Parenteral Pentamidine. 27th Intersci- ence Conference on Antimicrobial Agents and Chemotherapy, New York, 1987, #943. 14 Bernard, E et al. Safety and Effectiveness of Aerosol Pentam- idine for Prevention of PCP in Patients with AIDS. 27th Inter- science Conference on Antimicrobial Agents and Chemotherapy, New York, 1987, #944. 15 Boylen CT et al. Prospects for Prophylaxis and Treatment of PCP with Pentamidine Inhalation, presentation at MSKCC symposium, "Pentamidine Isethionate Inhalation: A Novel Therapy for PCP", New York, 10/4/87. 16 Rehm SJ et al. Blood Levels of Pentamidine in AIDS Patients Receiving Monthly Prophylaxis, Third International Conference on AIDS, Washington, 1987, WP.222. 17 Beisel, William R., Single Nutrients and Immunity, The Ameri- can Journal of Clinical Nutrition 35:417-467, 1982. 18 Levy, Beldekas, Black and Kushi. Patients with Kaposi's Sar- coma who opt for alternative therapy. Paris conference, June, 1986, Poster 42. 19 Levy, Cottrell, Kushi and Black. Patients with Kaposi's sar- coma who opt for alternative therapy: immune and psychological measures. Washington Conference, June, 1987, Poster WP.198. 20 Nawar, W.W: Lipids, in Fennema O (ed): Food Chemistry, New York, Marcel Dekker, Inc., 1985, pp. 231-233. 21 Artman, N.R.: The chemical and biological properties of heated and oxidized fats. Adv Lipid Res 1969, 7:245-330. 22 Kobayashi, S., et al. Lancet 2:197, 1981. 23 Lee, T.H. et al, Effect of dietary enrichment with eicosapen- taenoic and docosahexaenoic acids on in vitro neutrophil and monocyte leukotriene generation and neutrophil function, NEJM 312:1217, 1985. 24 Falutz, J. et al, Zinc Deficiency and Human Immunodeficiency Virus Infection, Washington Conference, Poster THP.133. 25 Duchateau, Jean, et al, Influence of oral zinc supplementation on the lymphocyte response to mitogens of normal subjects, AJCN 34:88-93, 1981. (1):101,1987. 27 Megadose Zinc Intakes Impair Immune Responses, Nutrition Reviews 43:141-143, 1985. &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& End of display