Distributed by AEGIS, your online gateway to a world of people, information, and resources. 714.248.2836 * 8N1/Full Duplex * v.34 **************************************************************************** AIDS TREATMENT NEWS Issue #225, June 16, 1995 phone 800/TREAT-1-2, or 415/255-0588 CONTENTS: Viral Load Predicts AIDS Progression Viral Load Reimbursement Information from Chiron Reimbursement Service Bioelectrical Impedance Analysis (BIA) May Predict AIDS Survival PI PERSPECTIVE May 1995 Now Available from Project Inform HIV Pathogenesis: Teleconference June 29 in Twelve Cities Merck Protease Inhibitor Trial Seeks Persons with CD4 Count Under 50 Internet: Pain Management Information on World Wide Web New York: AIDS Research Teach-In, June 24 San Francisco: Medical Marijuana on Viacom Cable, June 20 San Francisco: Sinusitis Study of Traditional Chinese Medicine California Residents: Medi-Cal May Pay Your Private Health Insurance Premiums Federal Employees: Insurance Open Season AIDSWatch '95 on Capitol Hill World Bank in AIDS Prevention Controversy "UN50" Demonstration June 25 in San Francisco Quote ***** Viral Load Predicts AIDS Progression by John S. James A prospective study of 62 patients found that viral load was the best marker available for predicting who would progress to AIDS: * Those who had a viral load of over 100,000 copies per ml on their first measurement after seroconversion were more than ten times as likely to develop AIDS as those who did not, during the followup time of this study (median somewhat under five years). * Blood samples from the 62 patients were saved at six-month intervals; the viral load test was later run on some of the samples obtained. Of those who had no samples over 10,000 copies in the first two years after seroconversion, the proportion developing AIDS was 6% of those whose CD4 (T- helper) count was under 500, zero for those over 500. But of those who had one or more sample over 10,000 copies in the first two years after seroconversion, 86% of those with CD4 under 500 developed AIDS -- as did 45% of those with CD4 over 500. These findings, from the Multicenter AIDS Cohort Study (MACS), were published in Mellors JW, Kingsley LA, Rinaldo CR, and others, Quantitation of HIV-1 RNA in Plasma Predicts Outcome after Seroconversion, ANNALS OF INTERNAL MEDICINE, April 15, 1995; volume 122, pages 573-579. The research was funded in part by the U.S. National Institutes of Health. ***** Viral Load Reimbursement Information from Chiron Reimbursement Service Testing for the number of copies of HIV RNA (the "viral load" test) is becoming more common in medical practice. But this test is not yet officially approved for use in managing patients. Therefore, health insurance and managed-care plans often refuse to pay for it. (Some do pay, perhaps because they realize that the test can cost less than continuing to use antiviral drugs which are not working for the patient). Chiron Corporation of Emeryville, California, one of the companies which makes a viral load test, has recently started a reimbursement hotline which may help patients and physicians get third-party reimbursement for the test, which costs about $200 each. "Chiron Reimbursement Service... provides reimbursement information and support to patients, providers, and payers involved in the delivery of the HIV-1 RNA assay. CRS offers assistance with benefit verification, appeals of denied or suspended claims, pre-authorizations of coverage, and insurance payment and policy information." The Chiron Reimbursement Service can be reached at 800/775- 7533. Note that Chiron is one of three major companies which make competing viral load tests. The other comparable tests are (1) quantitative PCR (by Hoffmann-La Roche), and (2) NASBA (by Organon Teknika), which is less well known in the U.S. than the others. Chiron has been more aggressive than the other companies in getting its test into clinical use. Comment Viral load testing is controversial, in that conservative researchers and physicians think its use is not justified until there is definitive proof that such use benefits patients. The problem is that the most definitive proof will take a long time to get, since "strategy" trials are may to be required. In these trials, which have not started yet, some patients will be randomly assigned to have their doctors use viral load in making decisions about what drugs they should use, while others will be randomly assigned to not use viral load. Even if nothing goes wrong with these trials, they will take a long time because they will have to wait for people to die or get sick, so that there can be a clinical difference between the two patient groups. But much could go wrong. Who will want to be in the control group and not know their viral load for years? What will stop them from secretly getting the test on their own, and then either dropping out, or changing their treatment without telling the researchers, if the results are bad? A more fundamental problem is that such a trial can only test one, or at most a few, strategies for using the viral load test. But we are in the early stages of learning how to use the test well. What result, for example, should be considered high enough to require a change in drug therapy? And when therapy is changed, should the patient add a new drug to his or her ongoing regimen, or change to different drugs, or try an entirely new class of antiviral such as protease inhibitors? If the strategy chosen for the viral load strategy trial happens to be a poor one -- which could easily happen, especially since the antiretroviral drugs now available are not very good -- it could take a long time to show its superiority (if any) over not using viral load testing at all. Given the current unknowns, it is likely that we will learn more about this test in the next several years through its flexible use in clinical practice, than by conducting any feasible set of rigid protocols. The FDA already accepts viral load testing for showing that a drug has antiviral activity in patients, for purposes of accelerated approval of the drug. And the available evidence -- plus all generally accepted theories -- strongly suggest that having a low level of virus in the blood is better than having a high level. We believe it is better to take a very small chance of being wrong, than to delay for years before using the best method available for quickly determining which antivirals are working for a particular patient. ***** Bioelectrical Impedance Analysis (BIA) May Predict AIDS Survival by John S. James An inexpensive, non-invasive electrical measurement predicted three-year survival better than CD4 (T-helper cell) count or any of several other measurements tested, in a recently reported prospective study of 75 patients.(1) In 1990, when the study began, the 75 patients had an average CD4 (T-helper) count of 176.2, and no AIDS-defining infections; a number of other baseline measurements were also recorded. During the 1000 days of followup, 29 of the 75 died of AIDS-related causes. Statistical analysis was used to see which of the baseline measurements were most predictive of survival three years later. Bioelectrical impedance is measured by a simple machine which can be used in a physician's office; the machine usually costs several thousand dollars, and the cost of bioelectrical impedance is generally reimbursed by insurance. The measurement consists of two numbers: electrical resistance, and capacitive reactance; from these numbers, a third number, the phase angle, can be calculated mathematically. >From these three numbers, plus the patient's height, weight, sex, and age, it is also possible to estimate body cell mass, fat-free mass, and other body parameters. These estimates, however, may be less accurate than the resistance, reactance, and phase angle, because their computation also requires certain constants, which have been derived from historical experience with other patients and therefore may not be entirely correct for the particular patients being measured. (The phase angle does not suffer from this inaccuracy, because it is computed entirely from the reactance and resistance of the patient who is being measured, without the use of any historical data derived from other patients.) The current study found that the phase angle was the best single predictor of who would survive for three years. Also, body cell mass, serum cholesterol, CD4 cell count, and serum albumin were predictive to a lesser degree, while age, weight, serum protein, and serum triglycerides were not statistically significant in predicting survival in this study. [Viral load was not measured in this research, so it could not be compared with BIA as a measure of survival.] Statistical analysis suggested that the volunteers with a median phase angle (which was 5.46 degrees in this study) had a somewhat greater than 50% survival during the 1000 days. Those at the 25th percentile (phase angle 4.87) [meaning that 25% of the patients in this study had a lower phase angle, 75% had a higher value] only had about a 15% survival. For those at the 75th percentile (phase angle 5.96), survival was better than 80%. [Caution: These numbers depend on particular characteristics of patients in this study, and also on certain statistical assumptions made by the authors; they cannot automatically be applied to other patients. Survival would almost certainly be better today, since treatments have improved in the five years since these patients were measured. And there are different kinds of BIA machines; the one used in this study was a single-frequency quadripolar model. Also, the measurements can vary depending on factors such as how much water is in the body, and whether one has certain opportunistic infections. The numbers above are included to help give a general picture of the test; but these specific figures cannot be applied literally in other contexts. Each patient needs to be evaluated individually -- and trends in repeated testing are usually more informative than single measurements.] The authors speculate that the phase angle may be a measurement of the electrical integrity of cell membranes. BIA has also been used as a measure of lean body mass, which is lost in wasting syndrome; in this study, however, patients started at an earlier stage of illness, without clinical indications of wasting. Other researchers have suggested that BIA may be a way of diagnosing wasting early, before it shows in weight loss or other symptoms. Comment This study only shows the value of BIA for prognosis -- predicting how well individual patients are likely to do. It does not show whether or not IMPROVING the phase angle, as a result of nutritional or other treatment, means that the patient is likely to live longer. BIA, however, is accepted as a means for measuring nutritional status and body cell mass, and has been validated for this purpose in AIDS patients.(2,3) Until more definitive information is available, it may be reasonable to accept improvement in BIA measurements as an indicator of improved health, as an indicator (although not proof) that a treatment regimen may have been working. Because of the small amount of electricity used in BIA, the only safety concern we have heard is for patients with implanted defibrillators. The ease and low cost of BIA suggest that this potential surrogate marker of HIV disease progression should be more widely studied and be more widely available. For More Information In December 1994, the U.S. National Institutes of Health held a major conference on bioelectrical impedance analysis. The proceedings of that meeting have been published.(4) Major chapters of the proceedings are: What does bioelectrical impedance analysis (BIA) measure? How should BIA be performed, and how can measurements be standardized? How safe and valid is the BIA technology in the estimation of levels of adiposity? What are appropriate clinical uses of BIA technology, and what are the limitations? How safe and valid is the use of BIA technology to estimate body cell mass and total body water status? For additional information about BIA, contact Cade Fields- Gardner, at The Cutting Edge, 708/516-2455. References 1. Ott M, Fischer H, Polat H, and others. Bioelectrical impedance analysis as a predictor of survival in patients with human immunodeficiency virus infection. JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES AND HUMAN RETROVIROLOGY May 1, 1995; volume 9, number 1, pages 20-15. 2. Sluys TEMS, van der Ende ME, Swart GR, van den Berg JWO, Wilson JHP. Body composition in patients with acquired immunodeficiency syndrome: a validation study of bioelectric impedance analysis. JOURNAL OF PARENTERAL AND ENTERAL NUTRITION 1993; volume 17, number 5, pages 404-406. 3. Jacobs, DO. Bioelectrical impedance analysis: A way to assess changes in body cell mass in patients with acquired immunodeficiency syndrome? JOURNAL OF PARENTERAL AND ENTERAL NUTRITION 1993; volume 17, number 5, pages 401-402. 4. NIH Technology Assessment Conference on Bioelectrical Impedance Analysis in Body Composition Measurement, December 12-14, Bethesda, Maryland. Sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases, and the NIH Office of Medical Applications of Research. ***** PI PERSPECTIVE May 1995 Now Available from Project Inform The new issue of PI PERSPECTIVE, a newsletter published three times a year, is now available. It includes articles on: * Research: "Last year has brought more advances in the treatment of AIDS than perhaps any similar period in the history of the epidemic" -- but complacency and lack of leadership have prevented their optimal use. * New antivirals: Major results of studies of d4T, and of 3TC. * Immune-based therapies: In-depth report on Project Inform's Immune Restoration Think Tank. * Protease inhibitors: Merck MK-639; Abbott ABT-538; Hoffmann-La Roche saquinavir; and Agouron AG1343. * CMV treatment advances: Ocular implants; HPMPC; combining ganciclovir and foscarnet. * Prophylaxis: Developments in preventing pneumocystis, fungal infections, MAC, CMV, and toxoplasmosis. * Kaposi's sarcoma: Controversies in interpretation of data on the important new drug DOX-SL, which is not yet approved but recommended for approval by an FDA advisory committee. * Pediatric AIDS: Advances and issues in the prevention and treatment of AIDS in infants and children. * How to interpret results of the quantitative PCR or branched DNA tests for HIV RNA copy number. * The Project Inform "Basic Message": Seven points on dealing with HIV infection. To obtain a copy of PI PERSPECTIVE and a basic treatment information packet call the Project Inform hotline, 800/822- 7422, or 415/558-9051, Monday through Saturday 10-4 Pacific Time. ***** HIV Pathogenesis: Teleconference June 29 in Twelve Cities An interactive video teleconference, "Understanding HIV Pathogenesis," will examine the treatment implications of new information about the virus and the immune response -- information first published by Michael Saag, M.D., David Ho, M.D., and their colleagues, in January 1995 (reviewed in AIDS TREATMENT NEWS #215, January 20, 1995). This video conference will be held June 29 between 6 p.m. and 8:30 p.m. Eastern time. The conference locations will open an hour early and serve light refreshments before the program. The conference, which allows participants in the 12 cities to ask questions of the speakers, will start with an overview of HIV pathogenesis by Dr. Saag, and a discussion of viral load by Mark Holodniy, M.D., of the VA Medical Center in Palo Alto. Following a question and answer session, there will be presentations by community representatives from the National Minority AIDS Council, ACT UP/New York, Project Inform, and the Treatment Action Group. The event is co-sponsored by the National Association of People with AIDS, the National Lesbian and Gay Health Association, the National Minority AIDS Council, and Project Inform, with an unrestricted grant from Burroughs-Wellcome Co. The teleconference will be held in Atlanta, Boston, Chicago, Houston, Los Angeles, Miami, New York, Newark, Philadelphia, San Francisco, San Juan, and Washington D.C. Each site will have a physician moderator and a community moderator. Spanish translation will be offered in San Juan, and halfway through the conference a Spanish summary will be transmitted to all 12 sites. This conference may also be accessed through non- interactive satellite downlinks at other locations; for more information, call the number below. For information about conference locations, registration, etc., call the teleconference coordinator at 800/555-9587 between 9 a.m. and 8 p.m. Eastern time. ***** Merck Protease Inhibitor Trial Seeks Persons with CD4 Count Under 50 Protocol 39, Merck's study of the protease inhibitor MK-639 in persons with CD4 count under 50, will recruit 420 patients at 12 U.S. sites. Enrollment should start in June or July. Other patients will be recruited in Canada, Australia, France, Germany, and Switzerland, beginning in September. The study will last six months; but after 12 weeks, certain patients in the blinded study may switch to open label. After the trial, there will be additional extensions if the drug is generally well tolerated and shows biologic activity. To enter the BLINDED portion of this study, patients need to have taken AZT for at least six months, and not have taken 3TC. They will be randomly assigned to receive either MK-639 alone, AZT plus 3TC, or a combination of all three drugs. They must discontinue treatment with AZT, ddC, ddI, and d4T two weeks before the study begins, and cannot use rifampin during the study. Volunteers who have not taken AZT for six months, or who are intolerant to AZT, or who have taken 3TC, may be eligible for an UNBLINDED portion of the study, in which they will receive open-label MK-639. Rifampin is permitted in this portion of the study. Additional entry criteria (for both portions of the study) include being at least 18 years old, not being pregnant, not having acute hepatitis, no prior use of protease inhibitors, no use of investigational agents or immunomodulators within 30 days prior to the study, and no use of immunosuppressive therapy within two weeks prior to the study. Also, the CD4 count must have been below 50 on two separate tests at least a week apart. There are additional safety criteria based on blood, urine, and other tests. For more information about Protocol 39, call the Merck protease inhibitor information line, 800/379-1332. ***** Internet: Pain Management Information on World Wide Web Educational materials on cancer and AIDS pain management are now available on the World Wide Web (http://www.roxane.com/). Materials include newsletters, clinical articles, slides, a schedule of upcoming seminars, and the cancer pain management guidelines from the U.S. Agency for Health Care and Research. [Technical note: At the present time, this World Wide Web site is set up only for a Netscape browser, and only works partially if you use any other kind. In will soon be updated to also work with a Mosaic browser.] This site has been created by Roxane Laboratories, Inc., and the Roxane Pain Institute. Roxane Laboratories, Inc. is a pharmaceutical company which sells a number of brand-name and generic pain-relief drugs. Comment Pain management information is important because it is widely recognized in mainstream medicine that serious pain is undertreated by physicians, due to lack of education, misunderstood concerns about addiction, reluctance to prescribe controlled substances, and for other reasons. Patients and their advocates can use this information to negotiate with their physicians when necessary for better pain treatment. ***** New York: AIDS Research Teach-In, June 24 On June 24, ACT UP/New York is sponsoring a teach-in, "AIDS Research: What's Wrong and What You Can Do About It," 2:00 to 4:00 p.m. at the Lesbian and Gay Community Center, 208 West 13th Street. ***** San Francisco: Medical Marijuana on Viacom Cable, June 20 A call-in program on medical marijuana, with guest Marcus Conant, M.D., and host Paul Causey, will be broadcast live on Tuesday June 20 at 8:30 p.m. on San Francisco cable channel 35. The taped program will be repeated Wednesday June 21 at 2:30 p.m. and 10:30 p.m., and Saturday June 24 at 11:00 p.m. For more information, call AIDS Update, 415/252-6306, or send email to aidsupdate@out.org. ***** San Francisco: Sinusitis Study of Traditional Chinese Medicine A study comparing Chinese medicine to conventional antibiotics for treatment of sinusitis is now recruiting. The study is being run by the Immune Enhancement Project, which has reported good clinical results with traditional Chinese medicine for treating this condition. Participants must have recurrent sinusitis documented by endoscopy and a paranasal computed tomography scan (which will be provided without cost to the participant), have had a CD4 count within 12 weeks, be 18 to 60 years old, and not currently be using antibiotics except Septra. (Antivirals are allowed.) They must not have used Chinese medicines for four weeks before the study, nor have any active opportunistic infection, or any reason to expect that they will not remain clinically stable for six months. There are also additional exclusion criteria. This study lasts 12 weeks, with 8 weeks of treatment followed by a one-month washout period. Participants will need to visit the clinic in San Francisco when they begin the study, and at weeks 2, 4, 6, 8, and 12. On the last visit they will have a computed tomography scan and endoscopic nasal exam. For more information, contact Elyse Graham, The Immune Enhancement Project, 415/252-8711. ***** California Residents: Medi-Cal May Pay Your Private Health Insurance Premiums The State of California Department of Health Services asked us to let our readers know that Medi-Cal can pay private insurance premiums, in some cases. This benefits the individual because private insurance is usually better than Medi-Cal. And California likes the program because it has saved an estimated $22 million for Medi-Cal during the last two years. To be eligible for these programs, you must be eligible for Medi-Cal, be enrolled in a health insurance plan (including COBRA continuation) or have an employer's group health plan available for enrollment, and have high on-going medical costs. For more information, talk to your MediCal eligibility worker, or call 800/952-5294, ext. 111, to ask about the HIPP and EGHP programs. ***** Federal Employees: Insurance Open Season Federal employees with a life-threatening illness can improve their financial condition by tens of thousands of dollars by taking advantage of a special open season, which ends July 21. During the open season, employees who are not insured can enroll in life insurance up to slightly over their annual salary, with NO physical examination or health questionnaire. This allows them to take advantage of a new "accelerated benefit" option, which allows those with a life expectancy of less than nine months to collect the above amount while they are alive. (Unlike "viatication," this provision allows them to receive almost 100 percent of the insurance amount in cash.) A little-known provision can double the amount for those expected to die before age 36. An estimated one third of unmarried Federal employees do not yet have life insurance. For them, this open period is especially important. Note on life insurance early benefits (for anyone, not only Federal employees): Tom McCormack of Affording Care, Inc., says that the best way to get money from a life insurance policy is through a private loan from friends, family, or relatives, in return for naming them beneficiaries; if they have equity but no cash, a reverse mortgage without monthly payments can be used. The second best way is through accelerated benefits, if available. The least desirable way is through viatication (sale) of the policy. Income from accelerated benefits or viatication is still taxable under Federal law. For more information, call Tom McCormack, 202/479-2543. ***** AIDSWatch '95 on Capitol Hill by Tadd Tobias A record number of individuals concerned about AIDS converged in Washington D.C. May 21-23 to learn about Federal AIDS issues and to lobby members of congress. This grassroots effort, coordinated by the National Association of People With AIDS and co-sponsored by 26 national organizations, brought together over 500 advocates including people with AIDS, caregivers and service providers from 38 states. The focus of this annual event is to educate members of Congress and ask for their support of AIDS issues. This year's agenda included: * Reauthorization and full funding of the Ryan White CARE Bill; * Maintaining Housing Opportunities for People With AIDS (HOPWA); * Supporting AIDS treatment research at the National Institutes of Health; * Sustaining community-based CDC AIDS prevention activities; * Protecting Medicaid's entitlement status; and * Opposing mandatory HIV antibody testing of pregnant women. Personal Observation As a participant in AIDSWatch I came away feeling optimistic about the democratic process. Although I had mentally prepared myself for meetings with an unsympathetic Republican controlled Congress, my experiences taught me the power of being involved. Most of my lobbying visits were held with legislative aides who consistently brought up the fact that individuals can and do make a difference. They repeatedly stressed how important it is to make our voices heard in Washington. It is apparent after this experience that they are unable to represent a silent constituency; letters and phone calls make a big difference. Even though it is unfortunate that we are unable to depend upon Congress to formulate sound public policy and advocate for the needs of people with AIDS without our involvement, it is reassuring to come away from this event knowing that most elected officials recognize the power of a vocal constituency and will respond accordingly. It isn't high-priced lawyers and smooth-talking lobbyists who can take credit for successes in Washington; it is the folks back home who make those phone calls and write those letters. ***** World Bank in AIDS Prevention Controversy by John S. James In strongly worded letters of May 18 and May 19, the World Bank tried to persuade the British journal AIDS not to publish an editorial review on AIDS prevention by researchers at the Center for AIDS Prevention Studies of the University of California. AIDS published the article anyway (Peter Lurie, Percy Hintzen, and Robert A. Lowe, Socioeconomic Obstacles to HIV Prevention and Treatment in Developing Countries: The Roles of the International Monetary Fund and the World Bank, AIDS. 1995; volume 9, number 6, pages 1-8.) Thesis The main point of the controversial article is stated in its first paragraph: " By the year 2000, 90% of all HIV infections will have occurred in developing countries. Worldwide efforts to stem the HIV epidemic have to date emphasized inducing behavior change in individuals at high risk for HIV infection. In this review we argue that social and economic forces have also played a role in promoting the spread of HIV, and that these have been largely overlooked in favor of factors that operate at the individual level. The failure to consider all aspects of HIV transmission may be inhibiting our ability to reduce the spread of HIV infection." The authors argue that an economic approach called structural adjustment programs "which began in the early 1980s and is spearheaded by the International Monetary Fund (IMF) and the World Bank, may have created conditions favoring the spread of HIV infection in the developing world." The authors point out that the current debt crisis of "developing" countries has not always been there but started after 1973, when the OPEC oil embargo quadrupled world prices for oil, and also led to a worldwide recession which decreased demand for those countries' exports. Developing countries borrowed to cover the shortfall; then interest rates greatly increased and the borrowing could no longer be sustained. The World Bank and International Monetary Fund responded by imposing structural adjustment programs on desperate governments of poor countries, which led to greatly increased hardship and reduction of public services, including health services, in order to control inflation and redirect production toward exports. The article is especially concerned about four alleged consequences of these programs: * The decline of the rural subsistence economy -- forcing rural farmers to leave their families to search for work in the cities, where they are more likely to contract HIV, and leading to higher food prices and worse nutritional status, increasing vulnerability to HIV. * Development of a transportation infrastructure. HIV notoriously tends to spread along truck routes. * Migration and urbanization. Between 1960 and 1990, the urban population growth in sub-Saharan Africa was higher than in any other region of the world. A consequence of this migration is that men are more likely to have multiple sex partners, and women are financially dependent and less likely to be able to negotiate for safe sex when their men return. * Reduced spending on health and social services. Health spending declined 26% in sub-Saharan Africa between 1980 and 1985. When the World Bank required Kenya to charge $2.15 for STD clinic services, visits fell 35-60%. In northern Nigeria, a 56% increase in the number of maternal deaths has been attributed to structural adjustment programs. The CAPS article recommends the following changes in development programs to help deal with these problems: * Focus on the satisfaction of basic human needs such as food, housing, and transport, by reducing spending on military and luxury goods. * Encourage diverse agriculture, instead of producing a few products for export. * Support marginal producers and subsistence farmers, by shifting from large infrastructure projects to small projects using appropriate technology. * Place more emphasis on human resource development in developing countries. * Move from paternalistic to cooperative development policy making, allowing the citizens of developing countries to be heard. * Change the charter of the World Bank and International Monetary Fund to allow rescheduling or canceling of debt. * The World Bank and International Monetary Fund should require an AIDS Impact Report on future adjustment programs, so that their influence on HIV transmission -- good or bad -- will be considered. Lead author Dr. Peter Lurie told the San Francisco newspaper BAY AREA REPORTER, "If we are serious about stemming this global epidemic, everything -- including these 'sacred cow' economic programs -- will have to be on the table." Antithesis World Bank officials, in letters to AIDS on May 18 and May 19, said that "this paper falls well below the critical standards and intellectual rigor for which AIDS has acquired a reputation. Some of it is just demonstrably wrong. Some reveals a very poor grasp of development economics, structural adjustment and the role of the World Bank and the IMF... To accept such flawed material as an Editorial Review appears particularly ill-advised..." "Much of the argument in the Review can be condensed into one sentence: Economic development, which disrupts traditional ways of life and leads to greater mixing of people through commerce and migration, is conducive to the spread of disease, including AIDS. That is broadly true, but then the disease-limiting conclusion should be to restrain development, or even to reverse it, ignoring the fact that economic development overall is responsible, through the growth of income and knowledge, for enormous reductions in disease burden. There is in any case no reason to single out one disease in determining development policy. The authors also ignore completely the question of whether, in economies badly out of equilibrium, there is any real alternative to adjustment, to putting one's economic house in order... "It is worse than a pity -- it is a shame -- that a reputable journal which would never think to publish medical nonsense, should allow itself to be used to publish nonsense of other sorts." Comment: Where the Process Stops Almost all AIDS prevention activity has focused on getting individuals to change their behavior. The contribution of the University of California article has been to open the door to thinking about institutional change as well, as an additional approach to preventing HIV transmission. The hidden issue in this case is what costs of economic reform are acceptable, and what costs are not. If the World Bank and International Monetary Fund designed economic reforms that would make it impossible for thousands of the rich and powerful to make a living, it is inconceivable that those programs would be implemented. Instead, the computers would continue to hum, the meetings and conference calls would continue to drone on, until another plan was developed. The new plan might not be as efficient as the first one. It might take longer to get results; it might even focus on the informal subsistence economies in which people were in fact surviving, and try to improve those, instead of trying to supplant them with big-organization, wage-work, export- oriented industries. Domestically, the comparable issue is the policies of the U.S. Federal Reserve, which control inflation by deliberately maintaining unemployment, forcing prices down through the desperation of workers. Here also the health impact should be weighed along with other factors when policy is set. But again reform is unlikely, as institutions are unlikely to acknowledge any responsibility for the health consequences of their actions. Both the authors of the article, and the journal AIDS, deserve credit for illuminating a problem which needs attention. But until there is the will to deal with the problem, it will be hard to find solutions. ***** "UN50" Demonstration June 25 in San Francisco A march to protest ineffective AIDS policies of the United Nations will take place in San Francisco on June 25. It is scheduled to meet at 12 noon at Castro and Market Streets, and march on Market Street and Van Ness Avenue to the War Memorial Opera House. The march is organized by CRASH (Coalition Responding to AIDS & State-sanctioned Homophobia). On the following day, June 26, the Opera House will be the site of the official commemoration of the 50th anniversary of the signing of the United Nations charter. Hundreds of reporters, and many world leaders including President Clinton, will be in San Francisco for that event. For more information, call Michael Petrelis at CRASH, 415/522-2939 (voicemail). Comment The "UN50" celebration, which officially started April 26, has received remarkably little attention in San Francisco -- which is surprising if only in view of the amount of disruption which is likely to occur when the event climaxes on June 26. We have heard little discussion of United Nations issues in the gay community, and found very little in the mainstream press. We would be surprised if one San Franciscan in ten even knows that UN50 is happening. Quote "What AIDS research lacks can be summed up in a few words: Leadership, Courage, and a Sense of Urgency. We will continue to see a slow but steady pace of advances without them, just as we do today, but the pity is that we could move so much faster and so much more effectively with them." Project Inform, "Advances, Challenges, and Growing Frustration," in PI PERSPECTIVE, May 1995. ***** AIDS TREATMENT NEWS Published twice monthly Subscription and Editorial Office: P.O. Box 411256 San Francisco, CA 94141 800/TREAT-1-2 toll-free U.S. and Canada 415/255-0588 regular office number fax: 415/255-4659 Internet: aidsnews@igc.apc.org Editor and Publisher: John S. James Reader Services and Business: Richard Copeland Thom Fontaine Tadd Tobias Statement of Purpose: AIDS TREATMENT NEWS reports on experimental and standard treatments, especially those available now. We interview physicians, scientists, other health professionals, and persons with AIDS or HIV; we also collect information from meetings and conferences, medical journals, and computer databases. Long-term survivors have usually tried many different treatments, and found combinations which work for them. AIDS Treatment News does not recommend particular therapies, but seeks to increase the options available. Subscription Information: Call 800/TREAT-1-2 Businesses, Institutions, Professionals: $230/year. Nonprofit organizations: $115/year. Individuals: $100/year, or $60 for six months. Special discount for persons with financial difficulties: $45/year, or $24 for six months. If you cannot afford a subscription, please write or call. Outside North, Central, or South America, add air mail postage: $20/year, $10 for six months. Back issues available. Fax subscriptions, bulk rates, and multiple subscriptions are available; contact our office for details. Please send U.S. funds: personal check or bank draft, international postal money order, or travelers checks. VISA, Mastercard, and purchase orders also accepted. ISSN # 1052-4207 Copyright 1995 by John S. James. Permission granted for noncommercial reproduction, provided that our address and phone number are included if more than short quotations are used.