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Published in the Bulletin of Experimental Treatments for AIDS September 1996 issue, by the San Francisco AIDS Foundation. |
The Options Project at San Francisco General Hospitalby Leslie Hanna Researchers at San Francisco General Hospital (SFGH) recently began an effort, called the Options Project, to identify, recruit and treat with a 3-drug regimen people newly infected with HIV. Currently, all participants are taking AZT, 3TC and indinavir; other combinations are possible. Each year in San Francisco, 600-1,000 people become infected with HIV. Many are young (18-24 years of age) gay and bisexual men. The aim is to find people early in infection, give them powerful antiviral drugs that will complement the immune system's anti-HIV action and, ideally, eliminate HIV from the individual. The events that occur in the first few weeks following infection are very important. During initial infection, HIV replicates at extremely high rates, and there are accompanying high blood levels of HIV. Symptoms (including fever, rash, sore throat, muscle aches, swollen lymph nodes and mouth or genital ulcers) may be absent, mild or severe, and characterize acute retroviral syndrome (ARS). Studies indicate that initial blood levels of HIV, as well as the intensity of symptoms in ARS, have predictive value; high blood levels of virus and severe illness are associated with more rapid HIV disease progression. One goal of the Options Project is to improve the course of disease in persons who have become HIV-infected, particularly those with severe ARS. Another goal is to explore the possibility of preventing long-term infection. This aspect of the work at SFGH has grown out of research showing that use of potent antiviral drugs can reduce HIV in the blood to undetectable levels. In the AIDS Clinical Trials Group (ACTG) study 076, when AZT was given orally to pregnant women in the third trimester, intravenously during labor and delivery, and then to both mother and infant after birth, perinatal infections were reduced from 25% to 8%. If a single drug like AZT can do that, more potent drugs used in combination should be even more effective at preventing the establishment of viral infection. Another important, case-control study involved healthcare workers. Healthcare workers with a deep wound infection due to injury from an HIV-contaminated implement who took AZT were less likely to become HIV-infected than healthcare workers with a deep wound infection who did not take AZT. These 2 studies suggest that treating someone early is important and that, if 1 drug has such a profound effect, 3 drugs should work even better. Housed at SFGH, the Options Project is a broad collaborative effort involving the San Francisco AIDS Foundation, Project Inform, Prevention Point, 18th Street Services and other AIDS service organizations, as well as private practitioners. Collaborators seek to identify people with new, acute HIV infection. This refers to infection in persons who until recently were known to be HIV negative or whose status is unknown who have engaged in high-risk behavior(s) associated with transmission of the virus (such as anal or vaginal intercourse without a condom or with a condom that breaks or sharing equipment for injecting drugs), and who then develop the symptoms of ARS. Such individuals may call the Options Project Hotline at 415-502-8100. Those who decide to enroll come into the clinic to be seen immediately, free of charge. HIV antibody and viral load testing are also free, and processed immediately; an initial follow-up appointment is scheduled for approximately 72 hours later. The viral load test results quickly identify who has actually become HIV-infected. In addition to people with acute infection, treatment through the Options Project is available to people known to be newly infected, defined as people who have received a newly positive HIV test result within the past 6 months, after a previous test that was negative for HIV antibodies. A unique and special feature of the Options Project is that people who are found to be HIV-uninfected after evaluation (perhaps they are found to have mononucleosis or strep throat) are referred to community programs like the Center for AIDS Pre-vention Studies (CAPS), where they can learn strategies designed to help them modify the behaviors that put them at risk for HIV infection. Thus, these individuals can learn how to avoid subsequent exposures. So far, without any advertising, the Options Project in the past 2 months has screened 29 people and identified 9 who are newly infected. Currently, all 9 are taking AZT, 3TC and indinavir, and "tolerating them well," according to James Kahn, MD, project director. "We may increase to 4 drugs if we can find a regimen that looks more promising," he adds. Kahn cautions that the results of this novel approach are not yet known. "Eradication may not be possible, but it certainly bears trying; certainly, we'll never know if it works if we don't try. It is not a cure; still, I am very hopeful that early intervention and treatment with powerful antiviral combinations and behavioral interventions, as offered by this project, will reduce the rate of new infections in the community. Finding people early in infection, before the virus has had a chance to destroy the immune system, at the least provides an important pathway for a person to effectively fight HIV." Leslie Hanna is Associate Editor of BETA. Options Project Hotline: 415-502-8100ReferencesCase-control of HIV seroconversion in healthcare workers after percutaneous exposure to HIV-infected blood: France, United Kingdom, and United States, January 1988-August 1994. Morbidity and Mortality Weekly Report 44(9): 29-33. December 22, 1995. O'Connor EM and others. Reduction of maternal-infant transmission of human immunodeficiency virus with zidovudine treatment. New England Journal of Medicine 311: 1173-1180. November 1994. Kahn J, MD. Personal communication. August 23, 1996. Page last updated 27 September 1996 |
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