The Washington Blade - February 18, 2000
Lisa Keen

For years, experts have noted that common infections, such as the flu, are more dangerous for people with compromised immune systems. Such people have a diminished ability to fend off such infections. But a study led by the National Cancer Institute has revealed more about how and why such secondary infections are so problematic. It indicates that after infection with the influenza virus, the flu-infected cells have an increased susceptibility to HIV infection. And there is a "marked boost in replication" of the particular form of HIV that infects these cells.

"Therefore, our results suggest that infectious agents such as influenza virus may impact HIV disease progression by increasing the susceptibility of cells to HIV-1 infection," wrote the authors.

"It is conceivable that any event that results in increased immune activation increases the number of potential HIV target cells and hence may indirectly accelerate virus spread," wrote the researchers. "Alternately, co-infecting agents may directly alter the susceptibility of target cells to HIV infection, and any agent that triggers increased [replication of HIV that targets these susceptible cells] could be viewed as a potential accelerator of HIV pathogenesis."

Swiss researchers: Don't hurry, be cautious

American experts and public health officials generally recommend that people with HIV infection begin combination therapy as soon as their CD4 counts go below 500 and/or their viral loads go above 10,000. Some European experts have recently tried to suggest taking another look at delaying therapy to preserve a patient's options and avoid the drug side effects and toxicities. Their suggestions have been generally pooh-poohed by Americans.

The latest suggestion of delay has come from the Swiss. In the Dec. 24 issue of the journal AIDS, they note that an analysis of records of more than 3,000 patients from the past several years indicated that delaying therapy "does not à translate into an increased risk of clinical disease progression."

Overall, about 10 percent of patients developed disease progression over about three years and the differences were not significant between groups of patients who started therapy early and those who did not.

"Our apparently contradictory findings on the utilization of therapy and progression of HIV disease in certain groups of patients suggest that after 3.5 years of follow-up, with currently available regimens, deferring [combination therapy] may not be detrimental," noted the report.

The revised U.S. public health guidelines issued Jan. 28 recommend doctors offer patients combination therapy once the patients' CD4 counts go below 500 and/or their viral loads go above 10,000 (5,000 for women). The new guidelines note that, "preliminary data suggest that treatment of primary HIV infection with combination therapy has a beneficial effect on laboratory markers of disease progression as well as clinical outcome."

The guidelines now suggest that it is important to lower a patient's viral load to below 50 copies per milliliter. And they "strongly recommend" a combination using two nucleoside analogs plus either indinavir, nelfinavir, efavirenz, or ritonavir plus saquinavir.

In brief ...

HERBAL WARNING: In a "research letter" in the Feb. 12 issue of the British medical journal The Lancet, researchers at the National Institute of Allergy and Infectious Diseases and elsewhere warn that people taking the protease inhibitor indinavir should not take the herbal remedy St. John's wort. According to the letter, St. John's wort significantly reduces the availability of indinavir, so much so that it "could lead to the development of drug resistance and treatment failure." They added that it is "reasonable" to avoid using the herb with other protease inhibitors and with non-nucleosides as well. St. John's wort, readily available at most grocers and drug stores, is used by some people to alleviate depression.

COGNITIVE AID: Doctors at Columbia University, the University of Rochester, and Johns Hopkins University reported in the January issue of Neurology that the use of a skin-patch form of a medication for Parkinson's disease appeared to have some "encouraging" benefit in alleviating cognitive impairment associated with HIV disease. The researchers emphasized that the study was small (only nine of 14 patients wore the patch).

FIRST AND LONG: DuPont Pharmaceuticals announced Feb. 10 that it has won Food and Drug Administration approval of its non-nucleoside efavirenz under the agency's new "duration of response" standard. The standard, adopted for use on HIV drugs in 1997, requires that a drug be both effective and durable. DuPont says efavirenz is the first anti-HIV medication to win the duration of response approval.
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Always watch for outdated information. This article first appeared in 2000. This material is designed to support, not replace, the relationship that exists between you and your doctor.

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