Perspective: Information, Inspiration and Advocacy for People Living with HIV/AIDS

Update con Os

CIVUV andl
Kaposi's Sarcoma
Recent study results show that the level of
cytomegalovirus (CMV) in blood is an important predictor of whether someone is at
risk for developing CMV disease. In one
study, people who had fewer than 100 CD4+
cells and who were positive for CMV by a
polymerase chain reaction (PCR) test were
3.4 times more likely for developing the disease with a 2.5 times greater risk of death
compared to those with no detectable CMV
levels. The risk of CMV disease increases
as CD4+ cell counts decline below 50. CMV
retinitis (in the eye) is the leading cause of I
blindness among people with AIDS. This
new CMV PCR test may help to determine
who might best benefit from CMV preventive treatment, such as oral ganciclovir. The
Food and Drug Administration (FDA) has
not yet approved this new CMV PCR test.
However, for those who are at risk and
considering CMV preventative therapy,
blood samples can be sent to certain laboratories which are performing thetest. For
contact information on these labs please call
the Project Inform hotline at 800-822-7422.
Results from a recent study comparing a
number of different approaches for managing CMV disease has shown that the combination of a ganciclovir (GCV) implant
(Vitrasert@) directly in the eye and oral
GCV is more effective than the GCV implant alone in both preventing the spread
of CMV to the unaffected eye or other organ systems and in prolonging survival.
While intravenous GCV appears to be
slightly more effective than the use of oral
GCV in stopping the spread of CMV
throughout the body, it was not as effective
in prolonging survival as the combination
oral and implant approach. This could be
due to the added toxicities of the intravenous therapy and the associated risk of bacterial infections that accompany the surgically implanted port for intravenous (IV)
administration of the drug.
Three hundred and seventy-seven people
with CMV retinitis in one eye received (IV)
ganciclovir (5 mg/kg every 12 hours for 14 -21 days followed by 5 mg/kg once daily), a

GCV implant alone or an implant + oral
GCV (1500 mg three times daily). The results are shown in Table 1.
There was a lower incidence of Kaposi's
Sarcoma (KS) among the groups that received IV ganciclovir and the implant + oral
GCV compared to people on the implant
alone,osuggesting thatrsystemic (throughout
the body) ganciclovir may be able to reduce the risk of KS. For a more complete
discussion regarding the issues to consider
in the prevention, treatment and maintenance of CMV disease, call the Project Inform hotline for the CMV Fact Sheet.
Hepatitis C
Results from a small study shows that
HAART can temporarily increase hepatitis
C (HCV) viral load levels.hNineteen people
who were co-infected with HCV and HIV
were evaluated after starting HAART. HIV
viral loads were significantly reduced after
six weeks of HAART and CD4+ cell counts
significantly increased, however, HCV viral
load increased about 300% above preHAART levels. HCV levels returned to preHAART levels after 17-32 weeks while
continuing on HAART.
HAART may result in a better immune response, destroying more HCV infected liver
cells, which could result in the release of
hepatitis C virus particles. Increasingly, providers are testing for HCV before starting
an individual on HAART. If someone is
HCV positive, careful monitoring of liver
function is encouraged. If someone is HCV
negative before starting HAART, but develops symptoms, treating HCV presumptively and testing for HCV with more sensitive tests (PCR) is encouraged. The common test for detecting HCV antibodies is
not very sensitive and physicians have reported false negative test results that are
clarified using tests which directly measure
for virus (e.g., PCR technology). In instances
where HCV disease emerges despite negative test results, it is not believed that
HAART caused HCV infection, but rather
that the test to detect HCV infection was
inaccurate. M

The Basic Message.o Get tested, anonymously., Learn your options and line up
your support.
o If positive: maximize your
health, get a complete
physical, a full immune health
workup and get informed!
(See Project Inform's
discussion paper "Day One').
/ Get baseline CD4+ and HIV
RNA tests, repeat quarterly.
Chart the trends. Women
should get "gyn" exams and
pap" tests every six months.
/' If the CD4+ trend is downward
or already below 500, and HIV
RNA above 5,000, or if HIV
RNA is above 30,000-50,000,
regardless of other factors,
optimize nutrition and consider combination antiviral
treatment.
/ If viral measures do not decline
below the limit of detection or at
least below 5000, consider a
more aggressive antiviral
regimen.
Z If the CD4+ trend stays below
300, consider preventive
treatment against PCP (oral
drugs if possible). If the count
continues to fall below 200,
reconsider an antiviral regimen if not already on one and
learn about preventive
treatments against other
opportunistic infections. Learn
about drug interactions.
/ If you have begun preventative
therapies and your CD4+ count
rises as a result of antiviral
therapy, remain on any
preventative treatments you
have started.
/' If CD4+ count stays below 75,
intensify monitoring, consider
prevention against MAC/MAI
and CMV infections. Learn
about preventive therapies.

Table 1: Ganciclovir (GCV) Treatment Methods
Incidence of extraocular
and second eye CMV Median survival
after 6 months times
IV GCV 17.9% 426 days
GCV implant 37.8% 388 days
GCV implant
+ oral GCV 22.4% 568 days

PI PERSPECTIVE

I NUMBER 23 NOVEMBER 1997

17