Doctors Winning Ground by Inches in Grim War Against AIDS
With little public notice, glacier-like progress is being made in the fight against the ravages of AIDS.
To be sure, a cure or a vaccine for the deadly acquired immune deficiency syndrome is years away, at best. But as some AIDS patients are discovering, doctors are slowly learning how to make life a little easier--and perhaps a bit longer--by treating the seemingly endless life-threatening illnesses that arise when the immune system stops working.
“We are now better at managing complications and anticipating the problems that can occur,” said Michael Gottlieb, the UCLA physician who treated some of the first known AIDS cases.
For now, that progress has to be measured in days, and perhaps weeks, rather than months. Yet such tiny, individual gains add up to years, considering the fact that by 1991, 270,000 Americans are expected to develop AIDS--more than 10 times the number of current AIDS patients.
Cripples Immune System
The AIDS virus cripples the body’s immune system, leaving it vulnerable to tumors and a variety of infections that may affect every organ in the body.
The three most common AIDS-caused illnesses are Pneumocystis carinii pneumonia, the leading cause of death in AIDS patients; Kaposi’s sarcoma, a rapidly growing skin cancer, and cytomegalovirus infection, which can cause illnesses ranging from pneumonia to blindness.
Less common but no less deadly conditions include meningitis, tuberculosis, a tuberculosis-like infection called Mycobacterium avium complex and toxoplasmosis, which is a parasitic brain and spinal cord infection that causes seizures and loss of sensation.
In addition, AIDS patients are frequently afflicted with uncomfortable yeast infections of the mouth and esophagus and other less-fatal but debilitating viral and bacterial infections that wear down the body’s defenses, causing repeated bouts of diarrhea.
Finally, up to 40% of patients have varying degrees of dementia due either to the AIDS virus itself or other infections.
At any one time, AIDS patients can suffer from more than one of these conditions--often from many of them.
Some Can Be Treated
Some of these conditions can be treated with some success, especially if they occur singly and are caught early. But sometimes such treatments, which usually involve highly toxic drugs, prove as debilitating as the illness.
The specific treatments for such ailments--and whatever success, if any--vary widely, depending on factors such as how long a patient has had AIDS, the number of his infections and the expertise of the hospital involved.
Some of the most hopeful results have been seen in the treatment of Pneumocystis carinii pneumonia, or PCP. It is the most common and often the first opportunistic infection to strike AIDS patients. It accounts for 57% of AIDS deaths.
The early symptoms include shortness of breath, tightness of chest, fever, chills and a non-productive cough. But in PCP, these flu-like symptoms quickly worsen, causing patients to seek medical attention.
Physicians are learning that the earlier PCP is diagnosed, the more likely its lethal effect can be delayed by antibiotics.
Greater awareness by patients of some of the first symptoms of oncoming illness has made earlier diagnosis--and treatment--possible. And new experimental drugs that arrest the spread of some infections at least temporarily are arriving on the scene.
Diagnosis Difficult
But distinguishing PCP from other kinds of respiratory infections--a crucial prerequisite to therapy--is not easy. A definitive diagnosis often requires sending a lighted fiberoptic scope down the throat to look for signs of inflammation in the lungs and to take a tissue sample to be tested for the presence of the Pneumocystis carinii organism.
In the early years of the AIDS epidemic, once PCP was diagnosed, patients were given an antibiotic called pentamidine. But the drug also causes severe side effects on the liver, bone marrow, pancreas and kidneys.
More recently, physicians have begun using two other antibiotics, trimethoprim and sulfamethoxazole, that seem somewhat more effective. But they too cause rashes, fever and severe bone marrow damage in about half the patients, requiring either the dosages to be reduced or stopped altogether.
Still, up to 75% of patients recover from their first PCP attack, usually after about three weeks, and many of them are able to resume normal living.
High Relapse Rate
But PCP has a high relapse rate within several months to a year. And on the second time around, the antibiotics work less well because the PCP organism will have become resistant to the drugs and because a second PCP bout hits a patient harder than the first.
Researchers around the country are testing several new drugs to overcome such problems.
In another experimental approach, some physicians, including those at UCLA, are trying to prevent PCP relapses by giving patients antibiotics or other drugs before any sign of reinfection.
The second most common illness to strike AIDS patients--affecting about 23%--is Kaposi’s sarcoma, a skin cancer that appears first as tiny, painless red or black lesions on the chest and arms.
Kaposi’s generally is not lethal except when it invades the intestinal tract, where it can cause perforations, or reaches the lungs, where it can cause pneumonia.
In non-AIDS patients, radiation and cancer drugs are standard treatments for Kaposi’s. But in AIDS patients, the combination of radiation and chemotherapy can prove too damaging to an already-crippled immune system.
So some researchers have experimented by treating such patients with combinations of cancer drugs without using radiation. Early on, the tumors temporarily diminished in the majority of the patients. But in time, more than half the patients have had relapses that didn’t respond to drugs.
Marrow Transplants Tried
Several years ago, scientists at UCLA and at the National Institutes of Health performed bone marrow transplants on AIDS patients in hopes of enhancing their immune functions. The three patients who received transplants at UCLA benefited only in minor ways, according to Ronald Mitsuyasu, a UCLA oncologist.
Other attempts to fight Kaposi’s involve the use of interferon and interleukin-2, two substances manufactured by the body to protect itself from disease.
In about a third of a small group of Kaposi’s patients at USC’s Norris Cancer Hospital, high doses of treated interferon have caused their tumors to partially or completely stop growing, according to Dr. Alexandra Levine. Similar results have been achieved at UCLA, according to Mitsuyasu. But he conceded, “So far, we don’t know what the optimal treatment for Kaposi’s is.”
Another major killer of AIDS patients is infection by the cytomegalovirus. CMV is a member of the herpes family that has the unusual capability of infecting every organ.
In the lungs, CMV infection is nearly always fatal. In the intestinal tract, it can cause severe diarrhea. In the adrenal glands or the heart, it can cause malfunctions in ways that add to the problems of treatment. In the retina, it can cause vision problems, including blindness.
No Effective Treatment
There is no cure or effective treatment for CMV infection. An investigative drug called DHPG appears to prevent blindness in some cases. But it also can have severe toxic effects on the kidneys that require it to be stopped. When that happens, the virus continues with its destructive effects.
CMV infection also is a suspected “co-factor” in Kaposi’s sarcoma. That is, CMV may be a necessary precursor to Kaposi’s. If a way is found to treat or prevent CMV infection, then Kaposi’s perhaps would not occur, or so the thinking goes.
Treating AIDS patients is so difficult because it is usually a combination of PCP, Kaposi’s, CMV, tuberculosis, meningitis, yeast infections or other opportunistic infections that eventually wear down a patient until no therapy works. That person literally wastes away.
Often, the exact mode of death is unclear.
“They get weaker and weaker,” Mitsuyasu said. “Sometimes it’s an unrecognized infection. Sometimes it’s an infection that affects the liver, the brain or the adrenal gland and the impairment leads to death. Sometimes a vital organ simply just gives out.”
Children with AIDS present distinctly different problems because they do not usually develop PCP and almost never get Kaposi’s.
Sinus, Ear Infections
Instead, they develop bouts of sinusitis and middle-ear infections that gradually progress to more life-threatening infections, according to Dr. Edward Gomperts of Childrens Hospital Medical Center of Los Angeles.
Recently, researchers at the Albert Einstein College of Medicine in New York gave injections of gamma globulin to AIDS children and found that such shots made the children more comfortable by reducing fevers and controlling some infections. But the children were still vulnerable to other infections that can be lethal.
“The patient with opportunistic disease is the forgotten patient,” said Dr. Constance Wofsy, co-director of the AIDS program at San Francisco General. “Theirs is a depressing situation. The goal of physicians is to provide them with as many comfortable symptom-free days as possible.”
Clearly, the best hope in the fight against the ravages of AIDS-caused infections is a cure for the underlying AIDS virus itself. But just when such a magic bullet would be discovered--if ever--is entirely speculative.
But a recent ray of hope came in an experiment in which 145 AIDS patients were given the antiviral drug known as AZT and 137 a placebo. In the AZT group, only one patient died; in the placebo group, 16 died.
Based on that promising development, the researchers took the unusual step of halting the clinical trial and gave AZT to the placebo group as well, as a humanitarian gesture. At that time, federal health officials also said they would make the drug available to about 6,000 other AIDS patients who already have had their first bout of PCP. But AZT appears to be “only one step,” in the words of Assistant Secretary Robert W. Windom of the Department of Health and Human Services.
Clinical trials testing the ability of at least six other drugs to kill the AIDS virus are going on. Experiments also are under way to test another half dozen or so immune-enhancing agents.
