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Cesarean
complications
A comparison of 86
HIV-positive women and 86 HIV-negative women undergoing cesareans
showed that positive women had more minor complications, such
as fevers, following surgery than negative women. However,
women with HIV viral loads between 1,000 to 10,000 were eight
times more likely to experience complications than were women
with undetectable viral loads.
In reporting these new findings
in the American Journal of Obstetrics and Gynecology,
Dr. Elisa Josefina Rodriguez and colleagues note that caution
is still needed in making a decision to deliver by cesarean
in positive women when not medically necessary. Elective cesareans
are shown to decrease the risk of transmission, but not any
greater than the use of potent HIV medications which significantly
decrease a mother’s viral load. Of course, HIV infection for
a child is in itself a major complication that should be considered
in making a decision.
HIV
drugs in pregnancy:
updated guidelines
The following is taken with permission
from a recent newsletter of WORLD, Women Organized to Resist
Life-threatening Diseases, in Oakland, CA.
On May 4, 2001 a Public
Health Service Task Force published updated guidelines on
how HIV drugs should be used in pregnant women with HIV. Other
aspects of health care for HIV-positive pregnant women—such
as preconception (before pregnancy) counseling, C-section,
and monitoring tests—are also discussed. Here are some of
the things in the guidelines and information about how to
get them:
• Treat (give drugs
to) all pregnant women… to reduce the risk of passing HIV
to the baby.
• HIV-positive pregnant
women should avoid or be extra cautious about certain drugs
or drug combinations. These include: ddI + d4T (in combination)
[Videx and Zerit]; the oral solution of amprenavir [Agenerase]
(capsule form is okay); hydroxyurea and efavirenz [Sustiva]
should be strictly avoided during pregnancy, and AZT + d4T
[Retrovir and Zerit] should not be used together in any HIV
patient, not just the pregnant ones.
• C-sections, done
at 38 weeks gestation, should be considered for women with
viral loads over 1,000 at 36 weeks. For women with viral counts
under 1,000 it is unlikely that C-section would provide any
added protection, though there’s not enough information to
be sure yet. Providers should get the mother’s full informed
consent before doing a C-section, because a C-section is major
surgery and poses risks to the mother’s health. [Editor’s
Note: A substantial review of elective—emphasis on elective—C-sections
in positive women found few major complications.—EV]
For more information,
• You can obtain the
full text of the new perinatal guidelines at http://www.hivatis.org
or by calling the HIV/AIDS Treatment Information Service (ATIS)
at 1-800-448-0440.
• You can also get
the most recently published report from the Antiretroviral
Pregnancy Registry (or have your doc report complications
to them, especially if you suspect your child has problems
related to your taking HIV drugs during pregnancy) from: The
Antiretroviral Pregnancy Registry, Research Park, 1011 Ashes
Drive, Wilmington, NC 28405. Call 1-800-258-4263 (free for
US and Canada), international telephone 1-910-256-0238. Fax
1-800-800-1052, international 1-910-256-0637 or +44 1895 825
005.
Lactic
acid and liver problems
Prominent HIV specialist
Dr. Andrew Carr of Australia and colleagues warned that people
with HIV may suffer liver damage without the usual symptoms.
They wrote a case study in The Lancet medical journal
in May about a positive man who had taken Retrovir (AZT, zidovudine)
by itself in the early ‘90s, stopped for three years, then
took a combination of Zerit (d4T, stavudine) and Videx (ddI,
didanosine). About a year after that he had weight loss, fatigue,
nausea, a distended stomach and difficulty breathing. Lab
work indicated that he had hepatitis (liver disease) and lactic
acidemia, both of which reversed after stopping meds. Later,
however, even though he had only slightly elevated liver function
tests and lactate levels were normal in his blood, the lactate
level in his urine was high. He soon died of internal bleeding.
The doctors noted that low-level lactic acidemia may be the
cause of ongoing liver damage that could be hard to detect.
They noted that the class of HIV drugs called nucleoside analogues,
from which all three of the drugs noted are taken, are associated
with lactic acidemia and mitochrondial toxicity, as found
in this patient.
More
lactic acid, with bone problems
Dr. Carr and two of
his colleagues also made a separate report linking lactic
acid to osteopenia. They reported that osteopenia (reduction
of bone tissue to below normal levels, which can weaken them
and eventually lead to fractures) is common in HIV-positive
men, but that men tend not to show symptoms of the condition.
The osteopenia was also associated with lower weight prior
to HIV therapy and with lactic acidemia due to treatment with
nucleoside analogs. The findings were published in the April
13th issue of AIDS.
Hep
C
The Food and Drug Administration
(FDA) has approved an “unbundled” version of Rebetron. The
combination hepatitis C treatment consists of Intron-A (interferon
alfa-2b) and Rebetol capsules (ribavirin), both made by Schering-Plough.
Rebetol capsules will now be available by themselves. The
Hepatitis C Action and Advocacy Coalition (HAAC) contends
that the capsules will be priced so high that doctors will
be discouraged from combining them with interferons from other
companies. These combinations may be more effective for some
patients. Compounded ribavirin is still available at a lower
price. Contact HAAC at HAAC_SF@hotmail.com.
UN
session on AIDS
The United Nations in June
held a special session on HIV/AIDS. An exhaustive list of
priorities were presented, among them the need for prevention
efforts for young people, ensuring rights for people living
with the virus and stronger commitments for fighting HIV—including
treatment—from all governments. For transcripts, video search,
and complete archived webcast from the special session, visit
http://www.kaisernetwork.org/
healthcast/un/aids/jun01.
HIV
drugs and insulin resistance
An association has been seen
between HIV therapy and insulin resistance, a condition whereby
the body is unable to adequately use its supply of insulin.
This hormone helps regulate sugar in the body. Insulin resistance
is in turn associated with all kinds of problems, including
diabetes and heart disease. Doctors giving the HIV protease
inhibitor Crixivan (indinavir) to 10 healthy people without
HIV observed that they developed insulin resistance after
four weeks on therapy. The men took 800 mg of Crixivan twice
a day. Dr. Mustafa A. Noor and colleagues reported their results
in AIDS. They noted that genetic factors need to be
examined and, of course, the other HIV drugs should be examined
for this effect. The reason why insulin resistance is being
seen is still unknown.
Circuit
party transmission
Circuit parties are large-scale,
razzle-dazzle dance parties and party marathons for gay men,
held around the country to raise money for HIV-service organizations.
The parties have drawn strong criticism for high incidence
of sex and drug use that potentially contribute to HIV transmission.
However, defenders say that transmission can occur anywhere,
not just at circuit parties. Kudos to researchers writing
in the American Journal of Public Health for reminding
people that unprotected anal sex may lead to transmission
owing to “a lack of knowledge about—or incorrect disclosure
of—current HIV status.” Gordon Mansergh and colleagues surveyed
295 men to document the sexual activity and drug use of the
circuit.
Methadone
cuts mortality
In the May issue of the American
Journal of Public Health, other researchers reported that
injection drug users who drop out of a methadone program are
more than four times likely to die of an overdose. They looked
at 827 participants of the Amsterdam Cohort Study. The researchers
stated that “harm reduction-based methadone treatment, in
which the use of illicit drugs is tolerated, is strongly related
to decreased mortality from natural causes and from overdose.
Provision of methadone in itself, together with social-medical
care, appears more important than the actual methadone dosage.”
They also noted that while HIV has increased deaths among
injection drug users, overdose remains a more common cause
of death for IDUs in most countries.
Gay
and lesbian healthcare not up to snuff
An online survey of lesbians
and gay men taken by GayHealth.com
found that 40% of the men had not been vaccinated against
hepatitis A and B. The potentially fatal infections are spread
through sexual contact and are more common among men who have
sex with men than among other groups. GayHealth.com associate
medical director Susan Ball said, “Every gay and bisexual
man should be vaccinated against hepatitis A and B. They are
serious conditions, especially for patients co-infected with
HIV.” As for the women, almost 18% report having never visited
a gynecologist and 23% report having not seen one in more
than two years. The report noted that yearly Pap smears are
the best defense against cervical cancer. The majority of
cervical cancer cases are caused by the human papilloma virus
(HPV), which can be transmitted by woman-to-woman contact.
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