The Northwest HIV/AIDS Electronic Update JUNE 2000
		David H Spach, MD, Medical Editor Kate Willner, Managing Editor Contents: Editor's Note Featured Articles Johns Hopkins Website Article Summaries Recommended HIV/AIDS Websites Telephone Consultation Trainings & Conferences Archives To Subscribe/Unsubscribe	Editor's Note: This is our 6th electronic HIV/AIDS Update. This newsletter features (1) an update on the current syphilis epidemic in King County, Washington state written by H. Hunter Handsfield, MD, (2) an article published in JAMA regarding recommendations on resistance testing generated by the International AIDS Society-USA Panel, (3) an article in the New England Journal of Medicine that summarizes the current state of the art on opportunistic infections, and (4) a variety of other summaries of HIV-related articles that deal with epidemiology, antiretroviral therapy, and drug-drug interactions. In May, the AIDS Education and Training Centers (AETC) National Resource Center (NRC) website was launched at the site <http://www.aids-ed.org/>. This resource center has been designed to serve as a central resource for the education of providers of HIV/AIDS care nationwide. This is a HRSA funded website run by three collaborating institutions: the Johns Hopkins University AIDS Service, New York State DOH AIDS Institute, and The CORE Center, Cook County Hospital. This excellent website features (1) ready access to Public Health Service/DHHS National Guidelines, (2) a mechanism for review and evaluation of the wide variety of professional and patient education materials currently in use by the AETC Program, and (3) "Ask the Expert", a question and answer forum in which health care providers can ask questions of and provide feedback to members of the various DHHS guidelines panels. Sincerely, David Spach, MD Medical Director NW AIDS Education & Training Center Division of Infectious Disease University of Washington Seattle, Washington

Featured Articles

(Editor's Summaries)

__*Update: Syphilis and Unsafe Sex in Men Who Have Sex with Men. H. Hunter Handsfield, MD; Director, STD Control Program; Public Health-Seattle & King County; Professor of Medicine, University of Washington [Unpublished Data]. King County's epidemic of early syphilis (e.g. recently acquired, infectious syphilis, including primary, secondary, and early-latent infections) continues unabated. Thirty cases were diagnosed and reported in the first 5 months of 2000, compared with 34 cases in July-Dec 1999 and 42 cases in Jan-June 1999. About 85% of cases continue to occur in men who have sex with men (MSM). The estimated annual case rate is approximately 160 per 100,000 MSM and approximately 1,000 per 100,000 HIV-infected MSM (e.g.: an astounding one percent of HIV-infected MSM are acquiring syphilis each year. By contrast, the rate is less than 1 case per 100,000 heterosexual men and women; nationally, the rate of early syphilis is 4-5 per 100,000. Gonorrhea and chlamydia in MSM also continue to rise; in 1999, the minimum rate of gonorrhea in King County MSM was approximately 450 per 100,000, compared with 50 per 100,000 heterosexual men and women. About 75% of MSM with syphilis and 20% of those with gonorrhea or chlamydia are HIV-infected. The median age of MSM with syphilis is 35 years, indicating that most cases are not occurring in young, newly sexually active men. Recently Los Angeles, San Francisco, San Diego and Cleveland have reported increased syphilis in MSM; as in King County, most infected persons also have HIV. It is likely that we are seeing the beginning of a national trend; indeed, syphilis in MSM may be the single greatest threat to CDC's nascent national campaign to eliminate syphilis. Most MSM with syphilis acknowledge unprotected sex with multiple anonymous partners, often in bath houses or sex clubs. Many are addicted to crystal methamphetamine or use inhaled nitrates (poppers). Preliminary analysis of anonymous behavioral surveys and STD screening in almost 1,000 MSM indicates that unsafe behaviors (e.g., anonymous sex and unprotected anal intercourse) are equally frequent in men evaluated at the STD Clinic as in non-STD clinics, such as the Harborview Medical Center Madison Clinic. A particularly disturbing finding was that rectal gonorrhea or chlamydial infection were substantially more frequent in MSM who stated they are HIV-infected than in HIV-negative individuals.

Comments: This is an excellent and timely summary by Dr. Handsfield. Additional comments on this issue are as follows:

__ The current rates of unsafe sex and STDs in MSM in the King County region are alarmingly high and may be similar to those seen in the late 1970s and early 1980s, before the appearance of AIDS. The reasons for reduced sexual safety are not clearly known, but probably include complacency engendered by improved HIV treatment and improved survival. Unsafe behaviors themselves imply a potential for HIV transmission, and the risk is markedly enhanced by the presence of inflammatory STDs. Therefore, this raises concern that HIV transmission may be increasing among MSM.

__ Most HIV-infected MSM with syphilis are getting health care; the epidemic is not confined to disenfranchised persons. Therefore, HIV/AIDS providers have a crucial role in prevention.

__ Dr. Handsfield has recommended that all MSM with HIV (and undoubtedly many other HIV-infected persons) should have periodic screening tests for STDs. In particular he recommends syphilis serology screening every 6 months (for patients known to be having sex with new, multiple, or anonymous partners and those who use amphetamines or poppers, every 3 months would be warranted). The latter group also should have periodic rectal cultures for gonorrhea and chlamydia.

__ Syphilis can be an extremely difficult diagnosis. Consider syphilis in the differential diagnosis of patients with unexplained skin rash, lymphadenopathy, or neurological manifestations.

__ Dr. Christina Marra and co-workers at Harborview Medical Center are currently studying antibiotic treatment responses of patients with neurosyphilis. If you have a confirmed case of syphilis (any stage of syphilis), consider contacting Dr. Marra at 206-341-5400 to see if the patient would be eligible for the study.

*Antiretroviral Drug Resistance Testing in Adult HIV-1 Infection: Recommendations of an International AIDS Society-USA Panel [MS Hirsch, et al. JAMA 2000;283:2417]: At present, there are two major organizations that publish important guidelines regarding antiretroviral therapy: (1) the DHHS panel and (2) the International AIDS Society-USA panel. The current article by the International AIDS Society-USA panel is an excellent overview that discusses resistance assays, specific resistance profiles, clinical data on resistance testing, how resistance data can be incorporated into clinical decision making, and specific recommendations regarding the indications for resistance testing. The highlights of the article are (1) a compendium of data of selected studies that supports the clinical utility of resistance testing [Table 1], (2) an up-to-date diagram that illustrates the most common primary and secondary resistance mutations [see Figure], and (3) a concise summary of recommendations for resistance testing based on available data [Table 2]. The authors recommend resistance testing in the setting of a first regimen failure, multiple regimen failure, or pregnancy. They also recommend considering resistance testing in patients with primary HIV and in those with established HIV who have not received therapy. The following is a summary of the key primary mutations illustrated in the Figure in the text. The primary mutations are the mutations that best correlate with resistance to antiretroviral medications.

Drug	Primary Mutation(s)
Nucleoside RTI
Zidovudine (AZT)   Lamivudine (3TC)   Zalcitabine (ddC)   Stavudine (d4T)   Abacavir (ABC)   Multi NRTI	70, 215 44, 118, 184 65, 69, 74, 184 75 65, 74, 151, 184 69, 151
Non-Nucleoside RTI
Nevirapine (NVP)   Delavirdine (DLV)   Efavirenz (EFV)	103, 106, 108, 181, 188, 190 103,181 103,188,190
Protease inhibitors
Indinavir (IDV)   Nelfinavir (NFV)   Ritonavir (RTV)   Saquinavir (SQV)   Amprenavir (APV)	46, 82 30, 90 82 48, 90 50, 84

                                

Selected Information from the Johns Hopkins Website http://hopkins-aids.edu/

(then click on "More News" to view an expanded list of article summaries)

ARTICLE TITLES

*HIV/AIDS Epidemic: Summary Fact Sheet

*Quantitation of HIV Type 1 RNA in Different Biological Compartments

* Violence Victimization After HIV Infection in a U.S. Probability Sample of Adult Patients in Primary Care

* Predictors of Virological Success and Ensuing Failure in HIV-Positive Patients Starting Highly Active Antiretroviral Therapy in Europe: Results From the    EuroSIDA Study

*Patterns of Resistance Mutations Selected by Treatment of HIV Type 1 Infection with Zidovudine, Didanosine, and Nevirapine

*Salvage Therapy for HIV-1 Infection-The Challenge Grows

*Sustained CD4 T Cell Response After Virologic Failure of Protease Inhibitor-based Regimens in Patients with HIV Infection

*Offering HIV Prophylaxis to People Who Have Been Sexually Assaulted: 16 Months' Experience in a Sexual Assault Service

*Prophylaxis Against Opportunistic Infections in Patients with HIV

*Updated Guidelines for the Use of Rifabutin or Rifampin in HIV-Infected Patients Receiving Antiretroviral Agents

*Cost-Effectiveness of Cesarean Section Delivery to Prevent Mother-to-Child Transmission of HIV-1

ARTICLE SUMMARIES

EPIDEMIOLOGY/TRANSMISSION

__ *HIV/AIDS Epidemic: Summary Fact Sheet: The following fact sheet has been provided by the Office of National AIDS Policy (202-456-2437) and http://depts.washington.edu/cfar/NWHIVUpdate/www.whitehouse.gov.

__ *Quantitation of HIV Type 1 RNA in Different Biological Compartments [RN Shepard, et al. J Clin Micro 2000;38:1414]: The authors performed HIV RNA quantitation on plasma and on various other body fluids including cerebrospinal fluid, saliva, breast milk, seminal plasma, and cervical-vaginal lavage fluid. The assay methods included NASBA and the Roche Amplicor HIV-1 Monitor test (RT-PCR). The best results were achieved by NASBA since inhibitors limited the usefulness of RT-PCR. In general, there was a good correlation between plasma, HIV RNA levels, and the corresponding non-blood samples, but the latter were typically 1 - 2 logs lower. Nevertheless there were some very important exceptions with seminal fluid and with cervical specimens.

Comment: This is an extraordinary study that utilized resources from Chapel Hill, North Carolina, Queensland, Australia, and St. Gallen, Switzerland. Despite extensive reference to HIV in non-blood compartments, there have been, with modest exceptions, relatively few studies to quantitate HIV RNA in anything other than blood. The Organon Teknika nucleic acid sequence-based amplification method (NASBA) performed "fairly well;" the RT PCR was adequate for cervical and cerebrospinal fluid, but was generally inferior with other body fluids due to the presence of inhibitors. It will be obviously important to examine the impact of antiretroviral therapy on non-blood samples using this technology.

__ * Violence Victimization After HIV Infection in a U.S. Probability Sample of Adult Patients in Primary Care [S Zierler, et al. Am J Public Health 2000;90:208]: This is a report from the HIV Cost and Service Utilization Study (HCSUS), which is a national sampling of randomized patients from randomized physician practices within randomized metropolitan areas. Participants were asked the following questions: "Since your HIV diagnosis, have you ever been physically hurt by your partner or someone important to you," and "do you think being physically hurt was related to or because of your HIV infection?" The results are summarized in the table below:

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ANTIRETROVIRAL THERAPY

__ *Predictors of Virological Success and Ensuing Failure in HIV-Positive Patients Starting Highly Active Antiretroviral Therapy in Europe: Results From the EuroSIDA Study [R Paredes, et al. Arch Intern Med 2000;160:1323]: EuroSIDA is a consortium of 17 European countries with a cohort of 7,331 patients with HIV infection. The current study is a retrospective analysis to determine factors associated with virologic success (defined as a viral load <500 copies/mL) in 1,469 unselected patients who initiated HAART therapy. The results showed that 80% of patients given HAART had viral loads <500 copies/mL at some time during a follow-up period of approximately six months. Virologic success was independently predicted by low baseline plasma HIV RNA level, high baseline CD4 cell counts, and initiation of three or more antiretroviral drugs. The results with these three factors were statistically significantly better by multivariate analysis.

Comment: There are probably no surprises here except that the overall result seems to be better than those achieved in many U.S.-based clinics, although it should be noted that the threshold to define virologic success was 500 copies/mL, only 24% of the cohort had IV drug use as a risk factor, and the patients were PI naive at baseline. The CD4 cell count results are possibly relevant to the current debate regarding use of a CD4 cell count threshold to determine when to initiate treatment. Other findings include the following: the median time required to reach undetectable viral loads was four months; at six months, 24% of the patients had viral rebound after achieving undetectable levels; and the median time to virologic failure after achieving undetectable levels was 19 months.

__ *Patterns of Resistance Mutations Selected by Treatment of HIV Type 1 Infection with Zidovudine, Didanosine, and Nevirapine [GJ Hanna, et al. JID 2000;181:904]: This is a substudy of ACTG 241, which was a randomized trial comparing AZT/ddI versus AZT/ddI/nevirapine (NVP). The study involved genotypic resistance testing of isolates from 57 patients who had received at least six months of treatment with an incompletely suppressive regimen. The most important observation concerns NVP-selected mutations. The predominant mutations among 30 isolates were 181C (50%), 190A (50%), and 101E (30%). The two mutations that confer clinically significant resistance to efavirenz, 103N and 188L, were found in only 27% of early therapy isolates and 33% of late therapy isolates. With regard to nucleosides, only two of 141 isolates showed the 74V mutation indicating ddI resistance. Most of the isolates showed AZT-resistant mutations, most commonly 41L, 215Y, and 70R.

Comment: This paper shows that patients who have failed NVP-containing combination treatment may still respond to efavirenz, but resistance testing is advocated to support this decision.

__ *Salvage Therapy for HIV-1 Infection-The Challenge Grows [J Mellors, J Montanerl Lancet 2000;355:1435]: This is a brief review of the Third International Workshop on Salvage Therapy held in Chicago, April 12-14, 2000. The main story was that investigators continue to report high rates of treatment failure with salvage regimens. Specifically, Moncroft of the Royal Free Center for HIV Medicine in London reported virologic failure rates in the Euro SIDA cohort of 50%, 70%, and 80% after first, second, and third courses of antiretroviral regimens. The summary stated that several trials showed that about 30% of patients with failure using PI-containing regimens responded to salvage treatment, and about 15% responded if the prior regimen contained an NNRTI. Robert Hogg from Vancouver provided yet another report indicating that experience of the provider was a strong indicator of better outcome for salvage regimens. Strategies to improve response include the avoidance of monotherapy, use of resistance testing, and promotion of favorable drug interactions, particularly the use of ritonavir with other PIs. The reviewers did not endorse the use of polypharmacy (mega-HAART) due to the lack of controlled trials and concern for toxicity. They also did not endorse "strategic treatment interruption" due to lack of controlled data and concerns for safety.

Comment: Nearly all studies since the inception of the HAART era in 1996 have shown that the best results are with the first regimen. There has been relatively little progress in defining methods to deal effectively with patients who have virologic failure, except for resistance testing. The most recent CDC statistics on HIV-associated mortality are sobering in showing that the dramatic declines of 1996-1998 plateaued in 1999.

__ *Sustained CD4 T Cell Response After Virologic Failure of Protease Inhibitor-based Regimens in Patients with HIV Infection [SG Deeks, et al. JID 2000;181:946]: This is a report from San Francisco General Hospital of patients with over 16 weeks of PI-based therapy initiated before March 1997 (to permit at least 96 weeks of observation). There were 380 participants who were categorized by virologic response as having a complete response (viral load <400 copies/mL), a partial response, transient response, or no response. The analysis, as summarized below, showed that theCD4 cell response was directly related to the degree of viral suppression, but even patients who had virologic failure showed sustained CD4 cell responses. Values for CD4 are expressed as cells/mm3 and values for viral load (VL) are expressed in log 10.

Comment: This is an important study for showing that CD4 cell responses correlate with viral suppression, but it also showed that many patients who represent virologic failures have persistent increases in CD4 cell counts relative to baseline. This is referred to as "discordant" or "paradoxical" CD4 cell responses. It is not clear if this is due to partial viral suppression or an alternative mechanism, but data presented by S. Deeks at the 7th Retroviral meeting suggest that "fitness" may explain some of these discordant results [7th CROI Abstract LB10].

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POSTEXPOSURE PROPHYLAXIS

__ *Offering HIV Prophylaxis to People Who Have Been Sexually Assaulted: 16 Months' Experience in a Sexual Assault Service [ER Wiebe, et al. Canad Med Assoc J 2000;162:641]: The authors report their experience with a project completed in the Sexual Assault Service in the Vancouver General Hospital Emergency Department. The Service began offering HIV prophylaxis in November 1996 for victims of sexual assault. During the first 16 months there were a total of 258 patients seen. Of these, 71 accepted the HIV prophylaxis, 29 continued treatment after completing a five-day starter pack, and eight completed the four-week course of treatment. After this initial experience, the Service decided to offer HIV prophylaxis only to those with a high risk for HIV infection.

Comment: The use of HIV prophylaxis for victims of sexual assault is controversial. The CDC does not recommend this on the basis of mathematical modeling, which showed that it is not cost-effective. The obvious counter argument is that the benefit demonstrated in health care workers should be offered to sexual assault victims regardless of cost. This study tends to show a relatively low rate of compliance, with only 40% completing more than five days of treatment. By contrast, the experience in San Francisco with patients who actually sought prophylaxis in the context of an HIV exposure showed that over 80% completed the four-week course of treatment.

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OPPORTUNISTIC INFECTIONS

__ *Prophylaxis Against Opportunistic Infections in Patients with HIV [JA Kovacs and H Masur NEJM 2000;342:1416]: This is one of the series of periodic reviews of opportunistic infection prophylaxis in HIV by Joseph Kovacs and Henry Masur. The following are highlights of this comprehensive state-of-the-art presentation:

__ Changes in OI complications: One major review reported that the frequency of OIs decreased by 55% from 1992 to 1997 [MMWR 1999;48 SS-2:1]. The greatest decline was in CMV retinitis, and the least change was for non-Hodgkin's lymphoma.

__ Compliance with guidelines: Guidelines were not followed for PCP prophylaxis in 20% of patients with indications [MMWR 1997;46 RR-12:1]. For MAC prophylaxis the rate of non-compliance was 50% [NEJM 1993;329:898].

__ Has the relationship between CD4 cell count and the occurrence of OIs been altered by treatment? No.

__ Does the nadir of CD4 cell count influence the risk of OIs? Yes. The EuroSIDA study, through observation of approximately 7,300 patients, showed that the frequency of OI was approximately three times greater for those with a CD4 cell count nadir <150/mm3 compared to those with a CD4 cell nadir above this level.

__ Pneumococcal vaccine issues: The authors recommend repeat immunization every 3-5 years "because antibody titers wane rapidly in patients with HIV infection" [Scand J Infect Dis 1998;30:597]. Patients immunized when the CD4 cell count was <200/mm3 should "probably be re-immunized if the count increases above 200/mm3."

__ PCP: The authors recommend avoidance of "high-intensity exposure" to ubiquitous pathogens such as P. carinii and MAC. For P. carinii, this means patients with PCP should not be hospitalized in a room with another vulnerable patient.

__ Varicella-zoster: Patients who are seronegative or have no history of chicken pox or shingles and are exposed to chicken pox or shingles should receive VZIG within 96 hours. This is standard, but the statement goes on to say that preemptive therapy with acyclovir, famciclovir, or valacyclovir after exposure in these patients does not have established efficacy.

__ Activity of TMP-SMX versus P. carinii: Despite concern about possible in vitro resistance, the authors state that there is no clinical evidence that TMP-SMX prophylaxis is becoming less effective.

__ T. gondii prophylaxis: The authors note that all recommended prophylactic regimens for PCP should be effective for toxoplasmosis with the exception of aerosolized pentamidine.

__ TB prophylaxis: The current duration of INH prophylaxis is nine months because the six month regimen is less effective [MMWR 1998;47 RR-20:1].

__ Secondary prophylaxis: This is recommended for all severe opportunistic infections including PCP, CMV retinitis, cryptococcal meningitis, toxoplasmosis, histoplasmosis, and coccidioidomycosis. Less serious opportunistic infections that may be treated at the time of recurrence include candidiasis, herpes simplex, and dermatomal zoster.

__ Discontinuing prophylaxis: There is substantial data confirming the safety of discontinuing prophylaxis with immune reconstitution for primary PCP prophylaxis, primary MAC prophylaxis, and secondary CMV retinitis prophylaxis. Their recommendation, commensurate with the CDC/IDSA guidelines, is to discontinue prophylaxis for these conditions and for T. gondii when pathogen-specific criteria for immune reconstitution is achieved.

__ Discontinuation of CMV secondary prophylaxis: As with the CDC/IDSA guidelines, the authors endorse cautious discontinuation of long-term maintenance therapy if the CD4 cell count exceeds 100 - 150 mm3 for three to six months, if the lesions are not sight-threatening, if there is adequate vision in the other eye, and the patient can be followed by an ophthalmologist. Evidence supporting discontinuation of CMV prophylaxis is provided in table 6 of the article, compiled from five published studies:

__ Restarting OI prophylaxis: The authors recommend restarting prophylaxis for those who do not have sustained immune reconstitution when the criteria for initiating this prophylaxis is reached. They acknowledge that there are no data to verify this recommendation, and they further acknowledge that patients with HIV viral loads >10,000 - 20,000 c/mL may have prophylaxis started earlier.

Comment: This is an excellent review by well qualified observers. Although a stated purpose is to update CDC/IDSA guidelines that were published in September 1999, there is little here that departs from that document. Somewhat surprising is the lack of mention of recent studies suggesting safety in discontinuing secondary prophylaxis for toxoplasmosis

__ *Stereotactic Biopsy of Cerebral Lesions in AIDS [PL Gildenberg, et al. CID 2000;30:491]: This is a retrospective review from the Houston Stereotactic Center of 250 stereotactic brain biopsies in patients with AIDS. The authors report that pathologically abnormal tissue was found in 246 (98%). The diagnoses included: lymphoma in 82 (33%), PML in 73 (30%), toxoplasmosis in 38 (15%), HIV encephalitis in 24 (10%), and tumors not usually associated with AIDS in 7 (3%). The biopsy diagnosis differed from the predicted diagnosis in 1/3. No diagnosis was established in just 5 (2%). Complications of the procedure included intracranial bleeding in 15 (6%) and lethal complications in 7 (3%). The authors conclude that stereotactic biopsy of cerebral lesions provides a high diagnostic yield and is reasonably safe.

Comment: The authors present an excellent experience in terms of diagnostic yield and safety for stereotactic biopsy of brain lesions in patients with HIV infection. There is substantial effort to develop diagnostic methods such as PCR on CSF as an alternative method to define the major lesions that were identified with this report. It is unfortunate that this report was not accompanied by this type of diagnostic assay to determine relative merits. Nevertheless, this is by far the largest stereotactic biopsy experience reported to date, and the results seem highly favorable. posted 4/21/2000

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DRUG INTERACTIONS

__ *Updated Guidelines for the Use of Rifabutin or Rifampin in HIV-Infected Patients Receiving Antiretroviral Agents [MMWR 2000;49:185]: These are updated CDC recommendations for the use of rifabutin or rifampin with PIs or NNRTIs. The concern is for drug interactions resulting from the activity of these agents with the cytochrome P-450 isoenzymes. Rifamycins induce CYP450. PIs inhibit CYP450 and NNRTIs are variable. The new data indicate that rifampin, previously considered contraindicated with any PI or NNRTI, can now be used with efavirenz, ritonavir, or ritonavir plus saquinavir (HGC or SGC). Rifabutin may be given with most of the PIs and NNRTIs, but the dose usually should be decreased, and it should be increased when given with efavirenz. The full listing of recommendations are summarized in the table below: Recommendations for Co-Administration of Antiretroviral Agents and Rifabutin or Rifampin

Agent	Rifabutin (RBT)	Rifampin (Rif)
SQV	SQV plus RTV RBT-150 mg 2-3x/wk	SQV plus RTV Rif-usual dose
RTV	RTV-usual dose RBT-150 mg 2-3x/wk	RTV-usual dose Rif-usual dose+
IDV	IDV-800 or 1000 mg q8h RBT-150 mg qd or 300 mg 2-3x/wk	Avoid
NFV	NFV-1000 mg tid or 1250 mg bid RBT-150 mg qd or 300 mg 2-3x/wk	Avoid
APV	APV-standard RBT-150 mg/d or 300 mg 2-3x/wk+	Avoid
NVP	NVP-200 mg bid RBT-300 mg/day+	Possibly+
DLV	Avoid	Avoid
EFV	EFV-600 mg hs RBT-450 or 600 mg/d or 600 mg 2-3x/wk+	EFV-600-800 mg hs Rif-600 mg/d or 2-3x/wk+

  

+experience limited

__________________________________________________

PERINATAL TRANSMISSION

__*Cost-Effectiveness of Cesarean Section Delivery to Prevent Mother-to-Child Transmission of HIV-1 [MT Halpern, et al. AIDS 2000;14:691]: The authors performed a cost analysis of cesarean section plus AZT compared to vaginal delivery in HIV-infected women receiving HAART. Results are shown in the following table:

	C-section + AZT	HAART
Cost/case avoided	$1,131	$112,693
Cost/year life saved	$17	$1,697

                                       

                                            

Comment: This study shows dramatic benefits for C-section in reducing the cost of HIV care. It should be acknowledged that cost-analyses of medical strategies are highly dependent on the data used for the model, and the results shown are highly variable depending on vertical transmission rates. The authors conclude that elective cesarean section could prevent 239 pediatric HIV-cases/year in the U.S. The U.S. Public Health Service/DHHS Panel on use of antiretroviral in pregnancy has not taken a stand regarding the C-section question, but this issue is high on the panel's priority list.

Recommended WebSites

The AIDS Education and Training Centers (AETC) National Resource Center (NRC) http://www.aids-ed.org/

HIV Treatment Guidelines http://www.hivatis.org/

Johns Hopkins AIDS Service http://www.hopkins-aids.edu/

UCSF: HIV Insite http://hivinsite.ucsf.edu/

Journal of American Medical Association (JAMA) http://www.ama-assn.org/special/hiv/

Northwest AIDS Education & Training Center http://depts.washington.edu/nwaetc/

Medscape (Infectious Diseases) http://www.medscape.com/Home/Topics/ID/InfectiousDiseases.html

The 7th Conference on Retroviruses and Opportunistic Infections http://www.retroconference.org/

Free Regional and National Telephone Consultation

MEDCON University of Washington Medical Consultation; for Medical Providers in Washington, Alaska, Montana, and Idaho Local: 206-543-5300 Long Distance: 1-800-326-5300

WARMLINE National HIV Telephone Consultation Service; for medical providers; offered 7:30am-5:00pm PST; detailed information on service provided on their website. 1-800-933-3413 http://www.ucsf.edu/warmline/warmline.html

PEPline National Clinicians' Post-Exposure Prophylaxis Hotline 1-888-448-4911 http://pepline.ucsf.edu/pepline/

Upcoming NW AETC Trainings and Conferences

HIV/AIDS Clinical Preceptorship Program for primary care providers, nurses, and pharmacists:  Please visit the AIDS Education & Training Center website at <http://depts.washington.edu/nwaetc/CourseDescription.htm> for information about preceptorship opportunities.

____________________

*WASHINGTON

HIV/AIDS Course for Providers in Correctional Facilities "Treatment of HIV/AIDS in the Correctional Setting" June 14, Dinner program in Spokane

"Update on HIV/AIDS Antiretrovirals"

Speaker: Stephen Tabet, M.D.

Assistant Professor of Medicine, UW

"Adherence and Substance Abuse"

Speaker: RJ Johnson

CCDC Chemical Dependency Specialist

NW AETC

For more information or to register, please email <kusachi@u.washington.edu> or call Seiko Kusachi at 206-221-4964

Eighth Annual HIV/AIDS Clinical Update for Nurses

June 21-22, 2000 Shoreline Conference Center in Seattle.

For more information contact cne@u.washington.edu.

AIDS Clinical Conference: The 3rd Tuesday of each month, 8:00 to 9:00 am. Harborview Medical Center, Research & Training Building Auditorium Seattle, WA University of Washington CME-accredited

June 20, 2000 "Ethical Issues in HIV Therapy" Greg McMillan, PAC Veterans' Affairs Medical Center Portland, OR

July 25, 2000 "Anemia in HIV/AIDS" Patrick Sullivan, DVM, PhD Centers for Disease Control and Prevention Atlanta, GA (PLEASE NOTE DATE--because of the international AIDS conference in South Africa, the July AIDS Clinical Conference will be held on the 4th Tuesday)

For further information on the AIDS Clinical Conference, or to be placed on the E-mail distribution list for notices of this conference, please E-mail <kwillner@u.washington.edu>.

ARCHIVES

Past and current issues of this electronic newsletter may be accessed at the following websites:

Center for AIDS Research http://depts.washington.edu/cfar/ (and click on "NW HIV Update Newsletters" in lower right corner)

AIDS Education & Training Center http://depts.washington.edu/nwaetc/ (Then click on "Courses and Services", then on "Electronic Newsletter".)

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