Being Alive; September 1996
William Mannion, RN

Two Key Studies of MAC Infections

A trial of azithromycin (Zithromax) vs. rifabutin (Mycobutin) as MAC prophylaxis showed greater efficacy and lower cost using azithromycin once weekly as opposed to rifabutin once daily. Further, azithromycin adds additional benefit to PCP prophylaxis for those already on Dapsone or Bactrim. A satellite meeting on MAC reached a consensus that macrolides (azithromycin or clarithromycin) are key components to MAC treatment; additionally, clofazime (Lamprene) is of little value in treating MAC. MAC has been a difficult OI to treat and this meeting should give clinicians some guidance in its optimal treatment.

Treating Fungal Infections

Fungal infections such as cryptococcal meningitis and candidiasis are often treated with fluconazole (Diflucan). Now a new formulation of the drug itraconazole (Sporanox) may offer an additional option. Itraconazole solution has greater bioavailibility than the capsules currently in use in the United States. The itraconazole solution is as effective as fluconazole in treating candidiasis infections. No data were presented on the development of resistance to itraconazole, an issue of concern with fluconazole treatment. Look for itraconazole solution to be released in the U.S. in the future; a new drug application has been submitted to the FDA.

Wasting Syndrome in Women

For the first time, significant information was presented on wasting syndrome in women. HIV+ women lose more fat than muscle, whereas hiv+ men lose more muscle than fat. One explanation for the difference is that hiv+ women are likely to be deficient in estrogen and progesterone while hiv+ men are likely to be deficient in testosterone. Studies are underway on the use of estrogen/progesterone replacement therapy in hiv+ women with wasting.

One study revealed that the strongest factor in weight loss was a decrease in oral intake. When one is sick or too tired to eat, it is important to remember that you must eat in order to maintain your weight and prevent wasting. Another study showed that both physicians and clients delayed initiating treatment for wasting once weight loss had been identified. As wasting is a significant cause of death in people with aids, once weight loss is identified aggressive action should be taken.

Complying with Drug Regimens

Compliance with prescribed therapy was a significant concern at the Conference. A study conducted at Johns Hopkins University of more than 200 clients revealed that almost 50% had missed one day of antiretroviral therapy in the previous week. Similarly, 53% of those prescribed TMP-SMX (Bactrim, Septra) had missed at least one dose. Those on drugs three times daily were more likely to miss doses than twice daily regimens (42% vs. 24%). One hopes pharmaceutical companies will take note when developing future therapies. Similarly, health care providers should work with clients to determine regimens which are easiest for clients to maintain.

When to Start Prophylaxis

A session on prophylaxis for OIs reviewed the standard of care for initiating prophylaxis. CD4 counts at which OIs should be prevented include: less than 200 CD4 cells/cc for PCP, less than 100 cells/cc for toxoplasmosis (if toxo antibody positive), less than 50-p;75 cells/cc for MAC, and less than 50 cells/cc for CMV. Much debate continues regarding the utility of fluconazole prophylaxis for fungal infections. Fluconazole does prevent fungal infections; however, in ACTG 816 resistance to fluconazole developed in approximately 6% of clients. Those with fluconazole resistant candidiasis may require IV amphotericin B therapy.

Another area of debate is whether to continue prophylaxis if the CD4 count returns above the level at which one begins prophylaxis. Some clinicians believe that the immune system will be able to prevent OIs and therefore prophylaxis is no longer needed. Other clinicians suggest the CD4 cell function is not fully restored and the need for prophylaxis continues despite the rise in CD4 count. Nearly all clinicians agree that once an individual has had a particular OI, secondary prophylaxis to prevent a recurrence is required at any level of CD4 count.

The Cost of OI Prophylaxis

Cost of prophylaxis was studied by the Harvard aids Institute. Health care economists evaluate the cost effectiveness of therapies by calculating the cost of treatment per year of life saved (YLS). Preventing PCP and toxoplasmosis with TMP/SMX actually lowers the lifetime cost of treating aids while prolonging lives. MAC prophylaxis with rifabutin costs $194,000/YLS; this can be lowered by using clarithromycin ($141,000/YLS) or azithromycin ($63,000/YLS). Fungal prophylaxis with fluconazole costs $721,000/YLS. CMV prophylaxis with oral ganciclovir costs $1,272,000/YLS; however, the authors pointed out that oral ganciclovir is more useful in maintaining quality of life (preventing loss of vision) than in prolonging life.

The authors suggest that programs with limited funds (such as the ADAP program) might consider making certain drugs available to all who qualify as opposed to allowing the first individuals access to all drugs and then placing later individuals on a waiting list. Cost of therapy and rationing of health care were frequent topics of discussion both in the sessions and in the hallways. Many individuals pointed out that the cost of aids is not only the direct treatment costs but also the loss of economic productivity due to the early deaths of so many.

Concluding Thoughts

The major focus of the International Conference on aids was on viral pathogenesis and antiretrovirals; great hope accompanies the increased knowledge gained this year. Although at first it appears little new information came out regarding OIs, actually there has been a refinement of treatment information and increased options for treating most OIs. The discussions of compliance finally made drug manufacturers and clinicians acutely aware of the difficulty clients may have in actually taking all these treatments. Clients and health care providers now have multiple treatment possibilities and should design a treatment plan which will work best for the individual client.

(William Mannion, RN, is Nurse Manager of the Immune Suppressed Unit at Midway Hospital, Los Angeles.)

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