Subject: GMHC Treatment Issues Vol. 6 No. 9 Date: Oct 1992 (1326 lines) &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& && T R E A T M E N T I S S U E S && &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& TREATMENT ISSUES Volume 6, Number 9 -- October 1992 The Gay Men's Health Crisis Newsletter of Experimental Therapies CONTENTS: [items are separated by "*****" for this display] Nutritional Supplements and HIV Infection Importance of Nutrition Malnutrition Vitamin Therapy and Megadosing Autoimmunity and HIV How to Find Out More Treating Symptoms Nutrient Chart Opportunistic Infections: Amsterdam Update II Mycobacterium Avium Complex MAC Treatment MAC Prophylaxis Pneumocystis Carinii Pneumonia (PCP) PCP Prophylaxis Cytomegalovirus (CMV) and HIV CMV Treatment Herpes Simplex Virus (HSV) Cryptosporidiosis Microsporidiosis PML Toxoplasmosis Toxoplasmosis Prophylaxis Candidiasis Cryptococcosis Treatment Briefs HIV and Sunlight Animal Rights and AIDS Research Chinese Herbs Ron Woodroof AIDS Research Budget Reduced Special Live Call-In Broadcasts "Living with AIDS" "Promising Drugs Down the Pipeline" "Negotiating Health Care With Your Doctor" ***** Nutritional Supplements and HIV Infection by Lark Lands, Ph.D. Reports have suggested that a deficiency in nutrients in the human body can be a serious early problem in HIV disease. Some have gone so far as to suggest that malnutrition may even compound or create immune dysfunction. It is fairly clear, despite the controversy surrounding the role of nutrition in HIV management, that strategies to replace nutrients can be an important part of AIDS treatment. A number of nutritional experts agree that restoring nutrients may be critical for restoring immune function and possibly preventing disease.[1] Recent research has confirmed that nutritional deficiency begins very early in the asymptomatic stages of the disease and grows worse over time.[2] In fact, nutrient deficiencies occur while T4 cell counts are still in the range of 500-700.[3] Additionally, it has been shown that nutrient supplementation may restore immune function in important ways and even boost T4 counts in people with early stages of disease.[4] The lack of education on nutrition in most Western medical schools combined with a lack of funding have prevented serious attention from being focused on this aspect of HIV infection. Since nutrients cannot be patented, pharmaceutical companies have little profit motive to fund such research. Even though thousands of published articles confirm the influence of nutrient status on immune functions, many doctors have largely ignored this part of patient health.[5] Recent published research supports the need for medical attention concerning nutrient deficiencies in order to achieve a complete HIV management strategy.[6] This article will explore the role and treatment of malnutrition in people with HIV disease. IMPORTANCE OF NUTRITION Historically, nutrition has played a peripheral role in medical treatment. Recently, however, many doctors are recognizing that this omission is an oversight, since replacement therapy has been shown to benefit people with HIV/AIDS. According to Marcy Fenton, M. S., a registered dietician and nutrition consultant to AIDS Project Los Angeles, "Practitioners must be aware that good nutrition is not an 'alternative' therapy; it is a fundamental component of medical care."[7] She asserts that an individually-designed nutritional program can boost immune function, increase the efficacy of other medical treatments, and improve energy levels and general quality of life. Indeed studies have shown that nutritional supplements like zinc, selenium, and vitamins C, A, E, and B together with AZT may increase AZT's antiviral effect while at the same time strengthening the immune system.[8] Conversely, malnutrition may contribute to development of opportunistic infections and physical deterioration and can be the underlying cause of death. Dr. Paul Cimoch, the Director of Medical Services at the Center for Special Immunology in Fort Lauderdale, sees a primary role for nutrition in treatment regimens and explains that good nutrition helps people with HIV, just as with any other infection, by providing the nutrients that an active immune system needs to function most efficiently.[9] Various nutritional therapies are being tested in the U. S. and abroad, and volunteer groups like the Treatment Alternative Research project are pushing for the development of clinical trials of nutrients and other "alternative" and non-pharmaceutical treatments.[10] MALNUTRITION The word "malnutrition" often conjures up images of emaciated people who do not have access to daily meals, but the technical application of the word is much more subtle than that. Most people with HIV disease do not know they are malnourished, since malnutrition is specific to the absence of vitamins and minerals essential to healthy body function. More than two dozen studies presented at the VIIth International Conference on AIDS in 1991 documented the importance of nutrient replenishment for people living with HIV. [11] A number of those studies reported that a large percentage of even asymptomatic people suffer from malnutrition, while those with advanced disease suffer almost universal nutritional deficiencies. University of Miami Medical School researchers presented evidence that nutrient deficiencies begin very early and have a significant influence on how well the immune system functions and how quickly HIV disease progresses.[12] They reported that correcting deficiencies in nutrients such as B-6, B-12, and zinc actually resulted in T4 cell increases. Other studies have shown that for people with HIV or AIDS the effects of malnutrition can be quite devastating. Ill effects include inefficient drug absorption due to changes in the digestive tract, increased risk of drug toxicity, increased fatigue, and decreased activation and elimination of drugs which are dependent on fat, protein, carbohydrates, vitamins, and minerals for proper use by the body. Malnutrition in AIDS can result from many different factors. Inability to take in a proper amount of nutrients can be the result of impaired swallowing and taste due to infections in the mouth or esophagus (such as thrush or herpes), AIDS medications leading to anorexia (loss of appetite), nausea and vomiting, or limited financial resources that make three square meals difficult to manage. Diarrhea and changes in absorption caused by bacteria, viruses, or parasites may impair nutritional intake. Some medications, particularly antibiotics, may change the normal bacterial composition of the intestine and interfere with breakdown of food. Finally, an increase in metabolism often occurs in many people with HIV and leads to an increased need for nutrients. The presence of HIV itself as well as some of its associated infections can increase the metabolic rate. For example, fevers increase a person's caloric requirements by 7% for every degree Fahrenheit above normal. The interplay of these three factors -- namely, diminished intake, malabsorption, and hypermetabolism -- usually occur simultaneously to deplete the body of nutrients.[14] VITAMIN THERAPY AND MEGADOSING For people who want to take supplemental vitamins and minerals in addition to a balanced diet, a multivitamin which provides at least 100% of the U. S. Recommended Daily Allowance (RDA) is preferable over individual vitamins because of lower cost and lower risk of toxicity. Individual vitamins can be used as supplements when needed. Multivitamins are also preferable because single-nutrient deficiencies are unusual. Clinical studies of people with immune dysfunction due to malnutrition usually reveal multiple deficiencies.[15] Therefore, a single, good multivitamin may be more cost-effective, safe, and logical than daily handfuls of a variety of vitamins. Furthermore, some vitamins like A and C are water-soluble and are excreted in the urine when super-saturation from megadosing occurs. Despite the high cost and time involved, megadosing has been effective for many people. Most studies of high nutrient intake in humans and animals have shown megadosing to be safe, and have demonstrated heightened immune function when supplements are given at two to five times the RDA. [16] The dangers of megadosing or vitamin supplementation have been overstated but caution should be exercised since toxic effects are possible when vitamins are used improperly. Routine blood tests can be used to monitor levels and ensure that supplementation does not produce toxic levels of vitamins and minerals. AUTOIMMUNITY AND HIV There is increasing evidence for an autoimmune aspect of HIV infection,[17] which may be treated with antioxidants and other nutrients that protect cell membranes and dampen the inflammatory response of the body to the infection (e.g., glutathione, coenzyme Q-10, vitamins C, E, and A, selenium, zinc, etc.).[18] According to Dr. Russell Jaffe, deficits in any of the 42 nutrients essential to immune competence can contribute to immune dysfunction and possibly cause autoimmune conditions.[20] Although reports in the medical literature are still controversial, some suggest that vitamin C leads to improved immune function. At the Linus Pauling Institute in Palo Alto, California, researchers have shown that vitamin C, a water- soluble antioxidant, may block the infection of cultured cells by HIV through some unknown mechanism. Vitamin C is distributed widely through the body and may increase the effectiveness of compounds such as N-acetyl-cysteine (NAC), a glutathione replenisher.[21] Researchers at the National Institutes of Health (NIH) and Cornell Medical College demonstrated that, in vitro, NAC slows HIV replication by inhibiting viral transcription (production of messenger RNA, the template for protein production). At Stanford Medical School, an inverse relationship between viral production and glutathione level was demonstrated. Clinical trials with antioxidants (NAC) and other glutathione precursors) in people with HIV are underway at a few research sites. In addition to antioxidants, it may be very important to address the other elements that can contribute to autoimmune conditions such as food and chemical hypersensitivities. Appropriate discovery of such sensitivities via tests like the serum ELISA/ACT -- followed by elimination of the foods or other items to which sensitivity is found -- may help counter the possible autoimmune component of the disease. Test kits are available to physicians through the Serammune Physicians Laboratory, 800-553-5472. HOW TO FIND OUT MORE Registered dieticians and naturopaths may know more about general nutrition than medical doctors, since they have much more extensive training in the area. Many are specifically knowledgeable about nutrition in people with HIV. Unfortunately, naturopathy is not covered by all health insurance and office visits may be as expensive as an appointment with a medical doctor (about $60-$100). Basic nutrition analysis can start at under one hundred dollars, but extensive comprehensive analysis can extend to several hundred dollars. Some naturopaths will work on a sliding fee scale and will find inexpensive ways to supplement the patient's diet. The American Association of Naturopathic Physicians in Seattle (206) 323-7610 can recommend a certified naturopath in your area who is a graduate of a four- year school with a course of studies similar to American medical schools. The author also has further information, available by sending a self-addressed envelope and $5.00-$10.00 to cover postage and handling to: Carl Vogel Foundation, 1413 K St. NW, Washington, D. C. 20005. ***** OTHER USEFUL HINTS * Water is critical for proper absorption of many vitamins and minerals. It also helps remove toxic substances (like cell wastes) from the blood. Drinking adequate amounts of water is recommended for people with HIV. Filtered water is best when available since contaminants have been removed. Drink at least eight glasses a day> * Boiling all drinking water was recommended to patients with less than 200 T4 by Dr. Brian Gazzard at the International Conference. This strategy is thought to inhibit cryptosporidia that causes diarrhea. * Diarrhea results in nutrient excretion before absorption into the body through the walls of the small intestines can occur. A strategy for controlling diarrhea followed at San Francisco General Hospital includes the "BRAT" diet: Bananas, Rice, Apples, Tea, and Toast. Because of the limited protein and caloric benefits of this diet, it should only be used as a supplement to control diarrhea and not as a standard menu. ***** TREATING SYMPTOMS [19] SYMPTOM SUGGESTED THERAPY Loss of appetite Zinc, multiple nutrients Weight loss Enteral and parenteral formulas, multiple nutrients Depression B-12, multiple nutrients Loss of sense of smell or taste Zinc, essential fatty acids, Potassium muscle cramps Magnesium, calcium, Vitamin E Nerve pain (some types) B-12, thiamine, choline, inositol Cognitive dysfunction B-12 (memory and concentration loss) Fatigue B-12, essential fatty acids, ascorbate, magnesium chromium, coenzyme Q-10 ***** SUGGESTED NUTRIENT SUPPLEMENTATION LIST [Editor's Note: This chart describes nutritional regimens recommended by the author, a trained nutritionist, with some additions from published articles and abstracts containing the latest nutritional research in AIDS Treatment Issues urges readers, as always, to consult with a trained professional and a doctor before changing treatment regimens, and to inform all healthcare providers when making significant nutritional alterations in your diet. It is important to note that not all trained nutritionists subscribe to the following regimens.] Paragraph Labels: NUT = Nutrient ACT = Activity AMT = Amount RDA = U. S. Recommended Daily Allowance HH = Helpful Hints NUT Acidophilus ACT Helps digestion; prevents yeast infections AMT 1/4 teaspoons or 2-4 capsules before meals RDA N/A HH Must be refrigerated. Can be found in health food stores NUT Antioxidant Formulas ACT Clears the blood of free radicals AMT 400-800 mg/day RDA 60 mg/day HH More than 1000 mg/day can be toxic, so check total daily intake from all supplements, including multi-vitamins. Examples of antioxidants are beta carotene, selenium, & glutathione. NUT Vitamin C (Ascorbic Acid; Ascorbate) ACT Works against bacteria, viruses & fungi; may stimulate white blood cells to combat stress. AMT 6-20 grams/day RDA 60 mg/day HH Generally non-toxic, but can cause diarrhea and urinary stones (rarely) in high-doses. NUT Beta Carotene (precursor to Vitamin A) ACT Helps thymic function; fights bacteria and viruses; lubricates the lungs. AMT 20,000-50,000 i.u.day RDA 5,000 i.u./day HH Considered non-toxic, even in large amounts NUT Coenzyme Q-10 ACT Keeps immune function, heart muscle, thymus & cell respiration healthy. AMT 30-180 mg/day RDA N/A HH Completely non-toxic in high doses; may help people taking AZT. NUT Essential fatty acids. ACT Counters fatigue & immune dysfunction; alleviates skin problems. AMT Omega-6 fatty acids such as gamma linolenic acid found in primrose oil & borage oil, 240 mg/day; Omega-3 fatty acids, such as eicosapen taenoic or docosa-hexanocic acid (Max EPA, 300 mg/day) RDA N/A NUT Folic Acid (B-Complex Vitamin) ACT Helps red and white blood cell formation & synthesis of hemoglobin. AMT 400-800 mcg/day for people taking AZT, ddI or ddC. RDA of 400 mcg is sufficient for people not taking those drugs. RDA N/A HH Should be balanced with B-12 intake. NUT Glutathione ACT Helps with the function of many immune system activities including growth. Long thought to be critical to healthy immunity. AMT 300-1200 mg/day RDA N/A HH Not known if oral forms can produce high enough levels in blood to be of use. NUT Vitamin B-6 ACT Helps in DNA production, red cell proliferation, protein metabolism. AMT 100 mg/day RDA 2 mg/day HH Most important of the B vitamins for people who are immune- deficient. NUT Vitamin B-12* ACT Most common deficient vitamin in people with HIV. Involved in red blood cell production. A recent study shows it may help with brain functions.** Helps people with anemia who are not taking AZT. AMT 500 mcg/day oral plus nasal or under the tongue to bypass absorption problems. RDA 6 mcg/day HH "Ener-B" is a nasal B-12 gel. It must be taken 2-7 times a week. NUT Vitamin E ACT Helps remove toxic substances from the blood; may increase efficacy of AZT, may enhance resistance to OIs & slow disease progression. AMT 800-1600 i.u./day RDA 30 i.u./day HH Doses over 800 may cause fatigue in some people. Check multiple vitamins for E & keep track of total intake. Avoid acetate esterfied form which has no antioxidant activity. NUT Multiple Vitamin/Mineral ACT Helps absorption & metabolism. AMT 3 capsules/day RDA N/A HH Use a bioavailable, hypoallergenic multiple with advanced forms of minerals (citrates, picolinates, ascorbates) & vitamin B-6 in the form of pyridoxal phosphate rather than pyridoxine) in amounts at least equal to the RDA. Take with three meals a day. NUT Zinc ACT May help in skin or taste/smell disorders. AMT 25-50 mg/day HH Toxicities are possible at more than 100 mg/day for long-term use. Balance long term use with copper (2-4 mg day). Use bioavailable forms of zinc, such as citrate or picolinate. * Ideally B-12 is taken by intramuscular injection. Dr. Pamela Jo Harris reports a need for very frequent injections (2000 mcg, an average of three times per week) to maintain B-12 levels in the blood. This recommendation far exceeds the infrequent and inadequate intervals (once per month or less) often practiced by physicians. For more information see Harris PJ & Candeloro P. HIV infected patients with B-12 deficiency and autoantibiodies to intrinsic factor. AIDS Patient Care 5(3):125-128, 1991. ** Beach R, Hommes JT, Cheeks R, & Kotler D. HIV & Nutrition: Round Table Discussion, VIII Int'l Conf on AIDS, Amsterdam, July, 1992. ***** FOOTNOTES 1. VIII Int'l Conf on AIDS, Abstract # PoB. 3675 & PoB. 3458, Amsterdam, July, 1992; Singer P et al. Nutritional aspects of the acquired immunodeficiency syndrome. Amer Journ Gastroent 87 (3): 265-273,1992. Beach R. Malnutrition in patients with HIV infection and AIDS. Nutr MD 15 (8):1-7, 1989. 2. VIII Int'l Conf on AIDS, Abstract # PuB. 7318, PoB3711, & PoB. 3698, Amsterdam,July, 1992; V Int'l Conf on AIDS. Abstract # 468, Montreal June, 1989; Harriman GR et al. Vitamin B12 malabsorption in patients with AIDS. Arch Intern Med 149:2039- 2041,1989; Beach RS et al. Altered folate metabolism in early HIV infection. JAMA 259:519,1988. 3. Beach R and Lefkowitz M. Nutritional aspects of HIV infection. PAACNOTES 1(6):221-223, November/December, 1989. 4. Brighthorpe IE. AIDS: Remissions using nutrient therapies and megadose intravenous ascorbate. Int'l Clin Nut Rev 8:53- 75,1987; and Baum MK et al. Association of vitamin B6 status with parameters of immune function in early HIV-1 infection. J AIDS 4:1122-1132,1991. 5. Gross RL & Newberne PM. Role of nutrition in immunologic function. Physiol Rev 60:188-302, 1980; Bedich A. Micronutrients and immune responses. Ann NY Acad Sci 587:168-180,1990; Beisel WR. Vitamins and the immune system. Ann NY Acad Sci 587:5 8,1990; and Beisel WR. Single nutrients and immunity. Am J Clin Nutr 35 [suppl]:417 468,1982. 6. VIII Int'l Conf on AIDS, Abstract # PoB. 3675, Amsterdam, July, 1992; and Newman CF. Nutrition in AIDS management: current choices, effective strategies. AIDS Patient Care 4:6- 9,1990. 7. Fenton M. A Guide to AIDS Research and Counseling. Focus 5 (2),1990. 8. VII Int'l Conf on AIDS, Abstracts # W. B. 2076, Florence, June, 1991. 9. Cimoch PJ. Supplemental parenteral nutrition for the treatment of protein-calorie malnutrition in HIV/AIDS patients. PAACNOTES 2 (1):15-17. 10. For more general information and information about trials, contact Treatment Alternative Research Project, c/o PWA Health Group, 150 West 26th Street, Suite 201 New York, New York 10001. Contacts for information are Jon Greenberg (212 673 0491) or Sandy Katz (212 388 9929), or the office (212 255 0520) or fax (212 255 2080). 11. VII Int'l Conf on AIDS, Abstracts # M. C. 3127, #W. B. 90, #W. B. 2421, #M. B. 3128, #T. U. A. 66, #W. B. 2166, #W. B. 2076; Florence, June 1991. 12. VII Int'l Conf on AIDS, Abstracts # M. C. 3127, Florence, June 1991. 13. Raiten DJ. Nutrition and HIV infection: A review evaluation of the existent knowledge of the relationship between nutrition and HIV infection. Special Report prepared for the Food and Drug Administration, November 1990: 48-51. 14. Task Force on Nutrition Support in AIDS. Guidelines for Nutritional Support in AIDS. Nutrition 5(1):39 46,1989; Resler S S. Nutrition Care of AIDS Patients. J. Am. Diet. Assoc. 88(7): 828-832,1988. 15. Raiten DI. Nutrition and HIV Infection: A Review Evaluation of the Existent Knowledge of the Relationship between Nutrition and HIV Infection. Special Report prepared for the Food and Drug Administration, November 1990, 43. 16. Watson RR, ed, Nutrition, Disease Resistance, and Immune Function. Volume in Immunology Series. New York City, M. Dekker Inc. 1984. 17. Hoffman G W et al. An Idiotypic Network Model of AIDS Immunopathogenesis. Proc Nat'l Acad Sci 88: 3060-3064,1991; Kion TA and Hoffman GW Anti-HlV and Anti-Anti-MHC Antibodies in Alloimmune and Autoimmune Mice. Science 253:1138-1140,1991; Maddox J. AIDS Research Turned Upside Down. Nature 353:297,1991; Ascher MS and Sheppard HW. AIDS and Autoimmunity. JAIDS 3:177- 191,1990; and Ascher MS and Sheppard HW. AIDS as Immune System Activation II: The Panergic Amnesia Hypothesis. JAIDS 2:95- 114,1990. 18. VII Int'l Conf on AIDS, Abstract # T. U. A. 66, Florence, July 1991. 19. Standish L. One Year Open Trial of Naturopathic Treatment of HIV Infection Class IV-A in Men. Journ Naturopathic Med 3(1): 42 64,1992. Pulse TL and Uhlig E. A Significant Improvement in a Clinical Pilot Study Utilizing Nutritional Supplements, Essential Fatty Acids and Stabilized Aloe Vera Juice in 29 HIV Seropositive, ARC and AIDS Patients. Journ Adv Med 3(4): 209- 230,1990; Jaffe R. M. Personal Communication, April 2,1992; Askanazi J. Personal Communication, May 4, 1992; and Lands LE. Personal Compilation of Data, 1985-1992. 20. Jaffe RM. Host Defenses: An Approach to Risk Identification and Risk Reduction in HIV+ Individuals. Manuscript in Preparation. ***** Opportunistic Infections: Amsterdam Update II by Gabriel Torres, M. D. This article is a continuation of Treatment Issues coverage of the VIII International Conference on AIDS, which took place in Amsterdam on July 18-24, 1992. A report concerning women and AIDS will be published next month to complete this series. MYCOBACTERIUM AVIUM COMPLEX Studies about the epidemiology of Mycobacterium avium complex (MAC) -- an AIDS-defining opportunistic infection (OI) that causes fevers, night sweats, and severe diarrhea -- have demonstrated that the infection occurs more commonly in patients with advanced HIV disease and low T4 cell counts. In one study MAC occurred in 18% of patients with T4 counts less than 50 and in almost 14% of patients with T4 counts between 50-100. One large study of 1,006 patients showed that MAC infection developed in 21% of patients one year after AIDS was originally diagnosed and in 43% within two years of diagnosis. Of this latter group, 39% with T4 cell counts under 10 developed the infection.[1] MAC TREATMENT Several researchers revealed new data concerning the treatment of MAC infection. Dr. Richard Chaisson, of Johns Hopkins University, presented a study comparing three doses of clarithromycin (500 mg, 1000 mg, or 2000 mg twice daily) as a single agent in the treatment of MAC.[2] The majority of the patients with evidence of MAC infection in this study became negative when tested after treatment with clarithromycin. The median time to infection-free blood by using the 2000 mg/twice daily regimen was 27 days compared with 55 days with the 500 mg/twice daily regimen, and 43 days with the 1000 mg/twice daily regimen. Fevers and night sweats improved in 47%-76% of patients. Resistance to clarithromycin was demonstrated in the test tube in blood samples from 22% of patients after 10-12 weeks of treatment. There was no association between the different doses and the development of resistance. The most common side effect of clarithromycin was nausea and vomiting, which occurred more commonly at the higher doses. In an Abbott-sponsored expanded access program of clarithromycin, the 1000/mg twice daily dose was associated with improved survival. Additionally, three other smaller studies indicate that clarithromycin monotherapy is effective in eradicating MAC from the blood, yet is hampered by the development of resistance. Further studies will test clarithromycin in combination with other agents to prevent such resistance. Another study evaluated ethambutol, rifampin and clofazimine -- each used singly -- and found that only ethambutol reduced the amount of MAC in the body, making it a possible agent for combination regimens.[3] MAC PROPHYLAXIS Various studies presented at the conference showed that rifabutin is effective in preventing MAC bacteria infection. One study presented by Dr. William Cameron from Canada compared rifabutin (300 mg/day) to placebo in 556 patients with AIDS and T4 cell counts less than 200. All patients were on antiretroviral therapy and PCP prophylaxis. Mean T4 cell counts were 61 for the rifabutin recipients and 55 for the placebo recipients. Patients were followed for 176 182 days. Twenty- four patients in the rifabutin arm developed MAC compared to 50 in the placebo arm. Survival was similar between both groups. Side effects of rifabutin included urine discoloration and occasional rashes. Fever and fatigue occurred more commonly among the placebo recipients, and rifabutin seemed to prevent declines in performance status. In another similar study presented in a report by Dr. Fred Gordin from the Veterans Administration Medical Center in Washington, D. C., MAC infection occurred in 9% of patients taking rifabutin, compared to 15% of patients taking placebo.[4] The time for a MAC infection to occur and the length of MAC-free survival were prolonged in patients on rifabutin. However, no difference in survival was noted between the two groups. Side effects of rifabutin in this study included a few cases of neutropenia (lowered neutrophil cell counts) and muscular and joint pain. Rifabutin did not affect liver function tests in either of the two large placebo controlled studies. A final study conducted by the San Francisco Community Consortium showed that clofazimine (50 mg/day) was ineffective in preventing MAC infection. Of 99 patients taking either the drug or a placebo, seven taking clofazimine developed MAC compared to six patients taking a placebo, after a mean follow-up of less than ten months.[5] PNEUMOCYSTIS CARINII PNEUMONIA (PCP) Two new treatments for PCP showed encouraging results compared to the standard treatment, which is Bactrim or Septra (TMP/ SMX). Dr. Emil Toma from Canada reported on the combination use of clindamycin/primaquine compared to TMP/SMX in a doubleblind, randomized trial of 56 patients with first episodes of pcp.[6] The dose of clindamycin was 600 mg every six hours intravenously for ten days followed by 450 mg every six hours orally. The dose of primaquine was 15 mg/day. The combination of clindamycin / primaquine was 92% effective compared to TMP/ SMX, which was 90% effective. Survival was similar in the two groups. Toxicity was less frequent and severe with clindamycin/primaquine, and shortness of breath resolved more quickly (within three days). Another comparative trial was presented by Dr. Walter Hughes from St. Jude's Children's Research Hospital in Memphis, Tennessee.[7] This trial compared 566c80, also called atoraquone, an oral Burroughs Wellcome drug, with TMP/SMX in 322 patients with mild-moderate PCP. In patients with mild PCP, both drugs were similarly effective (63%) in successfully treating PCP. More toxicity (19%) was noted in the TMP/SMX group. But more treatment failures (18% v. 7%) were observed in the 566c80 group. Similar findings were seen in the group of patients with moderate PCP. Survival was slightly better with TMP/SMX (99%) than with 566c80 (93%) within four weeks of completing therapy. People with diarrhea who were taking 566c80 seemed to have shorter survival times. This may be related to poor absorption of 566c80 in patients with diarrhea. PCP PROPHYLAXIS Various studies presented in Amsterdam reported new information on the prevention of PCP. Dr. Margaret Schneider from the Netherlands presented a comparative study of aerosolized pentamidine (AP) and TMP/SMX for the primary prevention of PCP in patients with less than 200 T4 cells.[8] AP was given at a dose of 300 mg once monthly and was compared to either double-strength or single-strength TMP/SMX given once daily. Both doses of TMP/SMX were more effective and resulted in no episodes of PCP, compared to 16 episodes in the group taking AP. However, no difference in survival was noted. In another large multicenter European trial, the combination of dapsone (50 mg daily) and pyrimethamine (50 mg weekly) given with folinic acid (25 mg weekly) was compared to AP (300 mg monthly) in patients with less than 200 T4 cells. Barely a year into the trial, which had by then enrolled 362 patients, researchers decided to stop the study because the dapsone/pyrimethamine arm showed a benefit in the prevention of toxoplasmosis. Notably, no differences in the prevention of PCP occurred (ten cases of PCP developed in each arm). However, 19 cases of toxoplasmosis occurred in the dapsone/pyrimethamine arm, compared to 32 in the AP arm. Death rates were similar in both arms. More patients had to discontinue dapsone/pyrimethamine (42) than AP (3) due to side effects, including skin rashes, neutropenia, fever, and anemia. Patients who discontinued dapsone/pyrimethamine ran a high risk of developing toxoplasmosis. Finally, one related report showed that 67% of patients with a history of allergy to TMP/SMX were successfully treated with dapsone.[9] CYTOMEGALOVIRUS (CMV) AND HIV CMV received attention at the conference as a potential co- factor in the progression of HIV disease and as a virus causing serious disease, such as retinitis and colitis. In one observational study of 1,002 persons with AIDS or ARC and T4 cell counts under 250 who were treated with AZT and followed for two years, CMV disease developed in 109 (11%) during follow-up.[10] Median survival after a diagnosis of CMV was 173 days. A baseline T4 cell count of less than 100 was associated with the development of CMV. Previous anemia, neutropenia, or herpes infections were also associated with the development of CMV. Several studies seemed to indicate that the presence of CMV infection was associated with a higher risk of developing AIDS. In one study by Dr. Roger Detels from UCLA, semen specimens were studied in a group of 164 HIV-positive men enrolled in the Multicenter AIDS Cohort Study (MACS).[11] Those who had CMV detected in the semen progressed to AIDS twice as fast as those who did not have CMV; these same participants were more likely to develop Kaposi's sarcoma (KS) or lymphoma. In another study from a group in Houston led by Dr. Sally Stroud, PCR tests were used to detect CMV in a group of 100 HIV-positive men.[12] After 14 months, 47% of the participants who evidenced CMV progressed to AIDS, compared to only 22% of those in whom CMV could not be detected. Mortality was greater among the CMV-positive participants (78%), compared to the CMV-negative participants (15%). This study may suggest that intervention with anti-CMV therapies may influence survival and disease progression. CMV TREATMENT Various studies examined ganciclovir and foscarnet as treatments for CMV disease. Dr. Henry Balfour from the University of Minnesota, after a review of several trials, concluded that while both drugs are 75%-80% effective in arresting CMV retinitis, most patients still experience disease progression despite maintenance therapy. Additionally, most patients have less than 30 T4 cells at the time of diagnosis of CMV retinitis. A previous trial, published earlier this year, had shown that foscarnet therapy was associated with a four-month survival advantage over ganciclovir, though both drugs were equally effective in treating CMV retinitis.[13] Dr. Judy Feinberg from Johns Hopkins University commented that though there was a four month survival advantage, patients on foscarnet spent 17% of that additional time receiving foscarnet infusions, which may negatively affect their quality of life. Dr. Catherine Katlama from France stated that twice-daily infusions of foscarnet are less toxic than three-times-daily infusions and just as effective. She recommended the use of isotonic saline (1000-1500 cc/day for induction, or 500-1000 cc/day for maintenance) to prevent some of the kidney toxicities of foscarnet. Increasing the infusion time also seemed to help prevent the abnormally low levels of calcium caused by the drug. One trial from Germany presented by Dr. Peter Maltes showed that the combination of ganciclovir and foscarnet was effective in the acute treatment of CMV disease.[14] Ten patients received the combination (at the usual doses) for three weeks followed by maintenance therapy with both drugs alternated every other day. One patient developed acute kidney failure during the induction and discontinued treatment. Eight patients had a positive response to the treatment during the induction phase. During the maintenance phase, three patients with CMV retinitis developed disease at a median interval of 42 days. One experimental therapy presented in a poster was the use of liposomal ganciclovir injected directly into the eye.[15] One patient who had ganciclovir-induced neutropenia received one injection which prevented reactivation of retinitis for at least 20 days. HERPES SIMPLEX VIRUS (HSV) Foscarnet is the therapy of choice for acyclovir-resistant HSV, although long-term maintenance therapy with the drug is required. Another promising topical therapy for this condition, presented by Dr. Harold Kessler from Rush Medical College, is with a drug called trifluridine.[16] The drug is usually used to treat herpetic eye infections. In an open label trial, 12 patients were treated with trifluridine applied directly to herpes lesions three times per day for 10-42 days. Eight patients responded and six experienced complete healing of lesions, within 42 days. The drug was administered as a 1% ophthalmic solution applied as a thin film and covered with bacitracin/polymyxin ointment and a non-absorbent dressing. The overall response rate to this therapy was 68%, and no toxic side effects were observed. Five patients developed satellite lesions which required treatment off protocol. However, since the treatment is not systemic, careful observation for additional lesions is advised. CRYPTOSPORIDIOSIS New information on cryptosporidiosis was presented in Amsterdam by Dr. Brian Gazzard from London. Diarrhea associated with the disease seems to occur in three patterns, including transient (randomly appearing and disappearing), chronic (continuing indefinitely), and fulminant (occurring suddenly and violently). These three patterns are associated with worsening survival times (60, 24 and 7 weeks, respectively). Stool concentration and small bowel biopsy remain the diagnosing tests available. Abnormal liver function tests in one retrospective series were associated with inflammation of the bile duct, pancreas and gall bladder in patients with cryptosporidiosis.[17] Dr. Gazzard stated that heating water inhibits cryptosporidia, therefore boiling water may be a preventive strategy for patients with T4 cells less than 200. Aminosidine sulfate was administered in a small trial at a dose of 2000 mg/day to 34 patients with cryptosporidiosis at St. Mary's Hospital in London.[18] Among 18 evaluable patients, nine cleared the disease-causing organisms from their stool. The number of bowel movements in these patients decreased from five per day to approximately two per day. Side effects from the drug included headache in one patient and a rash in another. In a second small series of four patients with cryptosporidiosis, letrazuril was given at a dose of 50 mg/day for 6 weeks.[19] Stool frequency decreased from 11 per day to four per day after six weeks. Cryptosporidia cleared transiently from the stool in two patients, yet all patients relapsed after three months. None was receiving maintenance therapy. Roxithromycin was effective in reducing cryptosporidial diarrhea in four patients treated with a dose of 300 mg/day for two weeks.[20] Three of four patients also cleared the organism from their stool. Finally, a study of the sandostatin analog, SMS 201-995, found the drug to be useful in decreasing the frequency of bowel movements in ten of 12 patients with cryptosporidial diarrhea who had failed all other therapies.[21] Overall survival for patients with cryptosporidiosis seems to have improved slightly. In one study of 66 patients, median survival was ten months, compared to previous reports which had shown an average survival of six months.[22] MICROSPORIDIOSIS Microsporidia received some attention at the conference, since various presentations implicated these organisms as the cause of diarrhea in 32%-50% of pathogen-negative diarrhea.[23] Several studies showed that the T4 counts of patients with microsporidia are usually less than 50. Dr. Douglas Dieterich presented a report of 24 patients treated with albendazole (400 mg twice daily) in an open pilot study. Twenty-two patients had E. bieneusi and two had the "new species," called E. cuniculi and E. hellem. Of 12 evaluable patients, 45% had a reduction in stool frequency, and the microsporidia were not found in small bowel biopsy specimens, after a course of albendazole for one month. Weight increased by an average of 7.5 lbs after a follow-up of almost four months. PML Only one study of PML was presented at the conference, by Dr. Carolyn Britton from Columbia University.[24] She used Ara-C (cytosine arabinoside) administered into the spinal cord in 13 patients with confirmed PML. Eight patients stabilized and improved; four stabilized for a period of up to two years, and four patients stabilized for a period of up to six months. Non- responders had larger lesions, major neurological deficits, and brainstem disease. She also described five patients who stabilized on AZT therapy and two who stabilized without AZT. Four additional patients had rapid disease progression despite AZT therapy and had a survival of only four to five months. TOXOPLASMOSIS A natural history study described the survival of patients after a diagnosis of toxoplasmosis as being an average of 320 days.[25] No difference in survival was noted between those treated with sulfadiazine/pyrimethamine (260 days) and those treated with clindamycin/pyrimethamine (280 days). Those patients who had to be switched from sulfadiazine/pyrimethamine to clindamycin/pyrimethamine survived an average of 360 days. One large study of Navy and Marine Corps personnel showed that cat ownership was not related to toxoplasmosis infection as measured by seroconversion.[26] The combination of dapsone (100 mg/day) and pyrimethamine (25 mg/day) was effective in six patients without significant toxicities.[27] The drug 566c80 was proven effective in one study from New York in reducing and stabilizing the size of toxoplasmic brain lesions and in preventing the development of new lesions in 11 of 14 patients treated with the drug at a dose of 750 mg four times daily for six weeks.[28] A final study of azithromycin at doses of 1200 mg/day, found the drug to be ineffective in two patients. However, the combination of 566c80 and pyrimethamine was effective in two of four patients who had failed 566c80 alone. TOXOPLASMOSIS PROPHYLAXIS In one French study comparing various maintenance regimens, pyrimethamine/sulfadiazine was superior to either pyrimethamine alone or pyrimethamine/clindamycin in preventing recurrences of disease.[29] Clindamycin was not tolerated because of toxicities (rashes and diarrhea) in over 40% of patients. Primary prophylaxis proved to be effective in various studies with fansidar,[30] dapsone,[31] dapsone/pyrimethamine,[32] trimethoprim/sulfamethoxazole,[33] and high-dose pyrimethamine (50 mg/day).[34] Studies seem to confirm that patients receiving either TMP/SMX or dapsone with or without pyrimethamine for PCP prophylaxis developed toxoplasmosis less frequently than those taking AP maintenance therapy. CANDIDIASIS In one Mexican study the risk of progression to AIDS among 64 HIV-positive patients with oral candidiasis and oral hairy leukoplakia was 26% at 12 months, 46% at 18 months, and 68% at 24 months.[35] In another study it was determined that oral candidiasis and oral hairy leukoplakia occur at the same rate after seroconversion.[36] Both of these studies suggest that the presence of these oral lesions should be used as endpoints to indicate disease progression in clinical trials. An association between candidiasis and cigarette smoking was discovered.[37] In a study of 135 HIV-positive women at Brown University, vaginal candidiasis was observed in 41% of the women with a mean T4 count of 424. Notably, vaginal thrush occurred earlier in HIV disease than oral thrush, which was found in 25% of the women with T4 counts of about 185.[38] One German study evaluated 69 patients with recurrent candidiasis receiving fluconazole (100 mg twice weekly) for prophylaxis.[39] Twenty-two percent of patients on this regimen relapsed with oral and/or esophageal candidiasis. Resistant strains did not occur, but culture of oral swabs revealed positive results in 60%, indicating that prophylaxis was not effective in eradicating the organism. One patient also developed cryptococcosis. CRYPTOCOCCOSIS Dr. Michael Saag reported that the overall incidence of cryptococcal disease in AIDS patients was 7%, with a mortality of 14%. He recommended the use of higher doses of amphotericin (0.7-0.8 mg/kg) for the initial two weeks of therapy followed by either fluconazole or itraconazole. A report from the Community Based Clinical Trial Network's Observational Data Base found a gender difference im the occurrence of the disease. In fact, of the 4,080 participants in the study, cryptococcosis was reported in 9% of men and 20% of women. Cigarette smoking was found to increase the risk of cryptococcal meningitis; 12 of 16 cases of cryptococcal meningitis reported cigarette smoking within 30 days prior to the diagnosis compared to two control groups.[41] The combination of fluconazole (400 mg/day) and 5- flucytosine cleared the infection from the brain in 72% of patients in one study. New agents that appear promising in the therapy of cryptococcosis include liposomal amphotericin (Ambisome) and amphotericin lipid complex. The latter cleared the fungus in eight of 12 patients after 6 weeks of therapy.[42] The higher dose used (5 mg/kg/day) was most effective. In a small German trial of liposomal amphotericin, 18 of 20 patients were cured or improved with an eradication of the fungus in 65% of those taking the drug.[43] FOOTNOTES 1. Nightingale S et al. Incidence of MAI complex bacteria in HlV-positive patients. J Infec Dis 165:1082 5,1992. 2. VIII Int'l Conf on AIDS, Abstract # We B 1052, Amsterdam, July, 1992. 3. VIII Int'l Conf on AIDS, Abstract # Po B 3087, Amsterdam, July, 1992. 4. VIII Int'l Conf on AIDS, Abstract # Po B. 3081, Amsterdam, July, 1992. 5. VIII Int'l Conf on AIDS, Abstract # PoB. 3345, Amsterdam, July, 1992. 6. VIII Int'l Conf on AIDS, Abstract # WeB. 1020, Amsterdam, July, 1992. 7. VIII Int'l Conf on AIDS, Abstract # WeB. 1019, Amsterdam, July, 1992. 8. VIII lnt'l Conf on AIDS, Abstract # WeB. 1018, Amsterdam, July,1992. 9. VIII Int'l Conf on AIDS, Abstract # PoB. 3301, Amsterdam, July, 1992. 10. VIII Int'l Conf on AIDS, Abstract # PoB. 3834, Amsterdam, July, 1992. 11. VIII Int'l Conf on AIDS, Abstract # PoB. 3325, Amsterdam, July, 1992. 12. VIII Int'l Conf on AIDS, Abstract # PoB. 3354, Amsterdam, July, 1992. 13. Mortality in patients with AIDS treated either with foscarnet or ganciclovir for CMV retinitis, NEMS 326 (4): 213- 20,1992. 14. VIII Int'l Conf on AIDS, Abstract # WeB. 1054, Amsterdam, July, 1992. 15. VIII Int'l Conf on AIDS, Abstract # PoB. 3131, Amsterdam, July, 1992. 16. VIII Int'l Conf on AIDS, Abstract # WeB. 1056, Amsterdam, July, 1992. 17. VIII Int'l Conf on AIDS, Abstract # PoB. 3220, Amsterdam, July, 1992. 18. VIII Int'l Conf on AIDS, Abstract # PoB. 3229, Amsterdam, July, 1992. 19. VIII Int'l Conf on AIDS, Abstract # PoB 3257, Amsterdam, July, 1992. 20. VIII Int'l Conf on AIDS, Abstract # PoB 3209, Amsterdam, July, 1992. 21. VIII Int'l Conf on AIDS, Abstract # PoB. 3212, Amsterdam, July, 1992. 22. VIII Int'l Conf on AIDS, Abstract # PoB. 3239, Amsterdam, July, 1992. 23. VIII Int'l Conf on AIDS, Abstract # PoB. 3340, # PoB. 3223, Amsterdam, July, 1992. 24. VIII Int'l Conf on AIDS, Abstract # Th B 1512, Amsterdam, July, 1992. 25. VIII Int'l Conf on AIDS, Abstract # PoB. 3224, Amsterdam, July, 1992. 26. VIII Int'l Conf on AIDS, Abstract # PoB 3275, Amsterdam, July, 1992. 27. VIII Int'l Conf on AIDS, Abstract # PoB. 3277, Amsterdam, July, 1992. 28. VIII Int'l Conf on AIDS, Abstract # PoB. 3185, Amsterdam, July, 1992. 29. VIII Int'l Conf on AIDS, Abstract # PoB 3218, Amsterdam, July, 1992. 30. VIII Int'l Conf on AIDS, Abstract # PoB 3230, Amsterdam, July, 1992. 31. VIII Int'l Conf on AIDS, Abstract # PoB 3244, Amsterdam, July, 1992. 32. VIII Int'l Conf on AIDS, Abstract # WeB 1017, Amsterdam, July, 1992. 33. VIII Int'l Conf on AIDS, Abstract # PoB 3312, Amsterdam, July, 1992. 34. VIII Int'l Conf on AIDS, Abstract # PoB 3198, Amsterdam, July, 1992. 35. VIII Int'l Conf on AIDS, Abstract # ThB. 1577, Amsterdam, July, 1992. 36. VIII Int'l Conf on AIDS, Abstract # PoB. 3369, Amsterdam, July, 1992. 37. VIII Int'l Conf on AIDS, Abstract # PoB. 3362, Amsterdam, July, 1992. 38. VIII Int'l Conf on AIDS, Abstract # PoC 4371 Amsterdam, July, 1992. 39. VIII Int'l Conf on AIDS, Abstract # PoB. 3252, Amsterdam, July, 1992. 40. VIII Int'l Conf on AIDS, Abstract # PoC 4356, Amsterdam, July, 1992. 41. VIII Int'l Conf on AIDS, Abstract # PoB. 3172, Amsterdam, July, 1992. 42. VIII Int'l Conf on AIDS, Abstract # PoB. 3132, Amsterdam, July, 1992. 43. VIII Int'l Conf on AIDS, Abstract # PoB. 3156, Amsterdam, July, 1992. ***** TREATMENT BRIEFS by David Gold HIV AND SUNLIGHT A recent article in Science (August 1992, vol. 257, pg 1211-12) reported a study demonstrating that ultraviolet (UV) light can activate HIV in animals. The most common source of UV exposure comes from sunlight. Sun lamps, tanning salons and PUVA la therapy for psoriasis and other skin diseases) can provide even higher doses of UV radiation. The suggestion that UV light may activate HIV was first made in 1988 by researchers at SmithKline and confirmed by findings in the lab of NIAID's own Anthony Fauci in 1989, as well as other labs around the world. The article in Science also reported that the FDA has begun to review the issue. Researchers believe that if they can determine the specific mechanism by which UV activates HIV, they may be able to design a therapy to prevent it. In light of these studies and other data concerning the sun and skin cancer, readers may choose to practice "safer sunning" by using protective lotions. ANIMAL RIGHTS AND AIDS RESEARCH Efforts by animal rights extremists to halt all medical research using animals may have a substantial impact on research into promising AIDS therapies and vaccines. Among the tactics used by these groups have been harassment of researchers and arson, bombings, and vandalization of research labs. The American Association of Medical Colleges has recorded over 3,700 incidents of harassment of researchers by animal rights extremists. Ingrid Newkirk, founder of one of the most active animal rights groups, People for the Ethical Treatment of Animals (PETA), has stated publicly that "Even if animal research resulted in a cure for AIDS we would be against it" (Vogue, September, 1989) and "Six million Jews died in concentrations camps, but six million broiler chickens will die this year in slaughterhouses" (Washington Post, 1983). In this writer's view, there are some legitimate points to the animal rights movement. However, the campaign of terror that has been directed at researchers and laboratories working to develop safe and effective treatments and vaccines for life-threatening conditions affecting men, women, and children around the world, is dangerous and should be publicly renounced by all who call themselves animal or human rights advocates. For more information call Americans for Medical Progress at (703) 486-1411. CHINESE HERBS Notes from the Underground, the newsletter of the PWA Health Group, reports that, Sho-Saiko-To (SSKT), a mixture of seven herbs that is widely used in China and Japan, inhibits HIV replication in the test tube. Studies were completed in "several reputable labs in the U. S." Based on this data, a Japanese pharmaceutical company, Tsumura, is seeking to begin clinical trials of SSKT on people with HIV. Of course, as was noted in Notes, many compounds inhibit HIV in test tube experiments, but do not produce a similar response in the body. Nonetheless, SSKT is completely nontoxic and is produced by a large, reputable company able to ensure sufficient quality control. Call the PWA Health Group at (212) 255-0520 if you would like assistance in importing SSKT. RON WOODROOF Treatment Issues mourns the loss of Ron Woodroof, founder of the Dallas Buyers' Club, who died of AIDS on August 14, 1992. Ron was a true fighter. In 1986, he was diagnosed as HlV- positive with nine T-cells. He decided to organize the Dallas Buyers' Club in order to oversee the importation of unapproved experimental AIDS therapies to thousands of people. His fighting spirit will be greatly missed. AIDS RESEARCH BUDGET REDUCED Despite the expansive spread of HIV in the U. S. land the world), actual funding for HIV/AIDS research at the National Institutes of Health (NIH) is being reduced. In 1992, the NIH AIDS budget was set at $841 million. For 1993, the President's budget proposed $873 million, although the NIH had requested $1.195 billion. The apparent 3.8% increase in the 1993 budget ends up to represent a reduction in funds, given the following: a 12% biomedical inflation rate; a total federal budget increase of 13%; and mandates to stretch research dollars to areas such as pediatrics, TB, and preventative vaccines. Incredibly, the House of Representatives reduced the President's pitiful figure even further -- leaving only $864 million. The Senate has now proposed a figure similar to the President's, and a House-Senate conference committee will decide on a budget somewhere between $864-873 million. We must examine closely our own failure to advocate effectively for an AIDS research budget. Some notable exceptions spring to mind, such as Project Inform's research lobbying efforts, United for AIDS Action's political organizing and voter registration efforts, and AIDS Action Council finally hiring a treatment/research specialist (the talented Derek Hodel). However, if truly effective therapies for HIV are to be developed, our overall efforts on behalf of a well-funded and guided AIDS research program need to be reviewed and expanded. ***** SPECIAL LIVE CALL-IN BROADCASTS "Living with AIDS" GMHC's Cable TV Show "Promising Drugs Down the Pipeline" October 15, 1992, Manhattan Cable TV, Channel 35, 10:30 PM Show will be Rebroadcast on Paragon Cable, October 21, Channel 17, 11:30 PM; QPTV (Queens), October 21, Channel 56, 9:30 PM "Negotiating Health Care With Your Doctor" November 12, 1992, Manhattan Cable TV, Channel 35, 10:30 PM Show will be Rebroadcast on Paragon Cable, November 18, Channel 17, 11:30 PM; QPTV (Queens), November 18, Channel 56, 9:30 PM Call (212) 247-8090 with questions ***** TREATMENT ISSUES EXECUTIVE EDITOR David Gold EDITOR Mary Beth Caschetta MEDICAL CONSULTANT Gabriel Torres, M. D. TECHNICAL COORDINATOR Paul Warren COPY EDITOR Gary Schmidgall WRITERS David Gold Lark Lands, Ph.D Gabriel Torres, M. D. DESIGNER Stephen de Francesco PRODUCTION MANAGER Adam Zachary Fredericks PROOFREADER Steven Humes OFFICE VOLUNTEERS Barclay Dunn Joseph Evans Edward Friedel Bradley Nance Gary Schmidgall Frank Schramm STUDENT INTERN Julie Francis Treatment Issues is GMHC's newsletter devoted to providing reliable information on experimental therapies. Describing an experimental therapy should not be construed as recommending it. All new treatments should be conducted under a physician's care. Treatment issues is published ten times yearly. All rights reserved. Non-commercial reproduction is encouraged. Subscription lists are kept confidential. Treatment Issues is supported in part by contributions made to the Richard Dunne Memorial Fund. Medical Information 129 West 20th Street New York, NY 10011 Copyright (c) 1992 Gay Men's Health Crisis, Inc. We Need Your Support Your contribution will help GMHC continue to publish Treatment Issues. All donations are tax-deductible. 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ORGANIZATION STATEMENT A copy of GMHC'S latest financial report filed with the Department of State may be obtained by writing to: NYS Department of State, Office of Charities Registration, Albany, NY 12231, or to GMHC. &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& End of display