By Alison McCook

NEW YORK (Reuters Health) - Doctors should not automatically give HIV drugs to every child who may have been accidentally exposed to the virus that causes AIDS, according to the American Academy of Pediatrics.

Although quickly starting treatment with HIV drugs -- an approach called post-exposure prophylaxis -- may reduce the risk that the virus takes hold after a suspected exposure, doctors need to first consider whether the risk of infection is greater than the risks associated with taking the drugs, they said.

By Keith Mulvihill

NEW YORK (Reuters Health) - A 39-year-old Harvard scientist previously diagnosed with AIDS has survived two years after a heart transplant, according to a report released Wednesday, which suggests that other HIV-infected patients may be possible candidates for heart transplant.

Because donor hearts are in such short supply, the medical community will need to decide if HIV-infected patients -- once considered ineligible for transplant due to a poor expected prognosis -- should routinely be put on transplant waiting lists, according to the report in The New England Journal of Medicine.

"This was a benchmark kind of study," said Dr. Gregory Curfman, executive editor of the journal. Curfman said that publication of the report should get the medical community thinking about the issue of organ transplantation in HIV-infected individuals.

The new study, along with preliminary results from studies of liver and kidney transplants, "provides hope" that some HIV-infected patients can benefit from a transplant, according to an editorial by Drs. Michelle E. Roland and Diane V. Havlir of the AIDS Division of the Positive Health Program at the University of California, San Francisco.

The National Institutes of Health is currently conducting a study of 150 kidney transplants and 125 liver transplants in HIV-infected individuals, they note.

"Originally that study was to include heart transplantations, but its design was revised to focus on those organs for which there is greater need," they write. "It is hoped that funds will become available to add heart transplantation if the preliminary results are positive."

Many transplantation centers have been hesitant to allocate donor organs to HIV-infected patients because it was believed that immune system-suppressing drugs -- which must be taken by transplant patients for the rest of their lives -- might further damage an HIV patient's already embattled immune system.

However research has begun to suggest that HIV infection does not necessarily affect how well the patient responds to the new organ. Furthermore, therapies that suppress the immune system do not appear to increase an HIV-infected patient's susceptibility to infections.

To date, the bulk of organ transplants among HIV-infected individuals have involved kidney and liver transplants.

Indeed, the study's lead author Dr. Leonard H. Calabrese of the Cleveland Clinic Foundation in Ohio and colleagues note that the need for heart transplantation among HIV-infected individuals is much lower than the need for liver or kidney transplants. This is because there is a higher rate of other illnesses such as hepatitis B or C and HIV-related kidney disease.

The 39-year-old transplant patient, Dr. Robert Zackin, a researcher at the Harvard School of Public Health, was infected with HIV in 1986 and diagnosed with an AIDS-defining infection in 1992. Zackin, who also happens to be a senior author of the report, also developed Kaposi's sarcoma, a type of cancer often found in AIDS patients. Zackin underwent a battery of treatments to fight infections in addition to chemotherapy for the cancer. However, he later developed heart failure, perhaps as a result of his anti-cancer treatment.

He underwent a heart transplant in February 2001. Now, more than two years after the surgery, Zackin reportedly has experienced no new or reactivation of opportunistic infections and anti-HIV therapy continues to keep levels of the virus low. What's more, he continues to work full-time and exercise regularly, the study indicates.

Still, Zackin's recovery has not been without complications, according to the report. He underwent several episodes of organ rejection, including other complications that now require that he receive blood transfusions every two or three weeks.

Commenting on the unusual circumstances in having an author of a case study also be the patient in a report, Curfman told Reuters Health that as far as he could remember this was the first time that the journal experienced such a situation.

"We felt that it was important that if (Dr. Zackin) was to be an author, he needed to be identified (as the patient)," said Curfman.

Moreover, Curfman added that the editorial team felt strongly that the study was important since few, if any, previous studies have documented an HIV-infected person with advanced disease getting a heart transplant.

"Given the assumption that (Zackin) had a legitimate place on the recipient list there is no reason to suggest that he is a less eligible candidate based only on his HIV status," said Dr. Holly Taylor, of the Berman Bioethics Institute at Johns Hopkins University in Baltimore, Maryland.

"All of the people on the list have a fatal illness given that they all need a new heart," Taylor said in an interview. "The fact that (Zackin) has HIV doesn't mean that he won't benefit any less."

NEW YORK (Reuters Health) - People who are addicted to cocaine who undergo drug counseling reduce their cocaine use and significantly decrease their HIV risk, according to a new report.

"Drug abuse treatment can have important positive public health benefits even if the outcomes are less than perfect," lead study author Dr. George Woody told Reuters Health. "The 12-step oriented combination of group and individual counseling worked the best, though all patients reduced their risk."

Woody urged everyone to "support substance abuse treatment. It can do a lot of good both in the short and long term."

In an article in the Journal of Acquired Immune Deficiency Syndromes, Woody, who is at the University of Pennsylvania in Philadelphia, and his colleagues report on changes in HIV risk among 487 people undergoing treatment for cocaine addiction.

Treatment was associated with an average reduction of cocaine use from 10 days per month to one day per month after six months, the authors report, with participants who received both individual and group drug counseling faring best.

Treatment participation was also associated with significant reductions in risky sex and the total risk of HIV infection, the report indicates.

Those who completed treatment showed a trend toward less sex risk and significantly less total risk than did patients who dropped out before completing their program, the researchers note.

HIV risk reduction corresponded to reductions in drug use and to improvements in psychiatric symptoms, the results indicate. This improvement was similar regardless of race, gender, sexual orientation or the presence of antisocial personality disorder.

"The fact that all treatments consisted of no more than three weekly outpatient sessions that included risk reduction counseling is worth noting," the authors conclude, "because it suggests that reductions in cocaine use and HIV risk can be achieved at a relatively low cost, at least for a portion of the patients who seek treatment for cocaine dependence."

SOURCE: Journal of AIDS 2003;33:82-87.

[Home]  [Previous news]