Better Treatment, Longer Lives

Stories about medical breakthroughs are tough to resist. A wonder cure. A life restored at the stroke of a scalpel. That kind of article is exciting to writers and captures readers' imagination. This, however, is another kind of medical tale -- one that is more faithful to the way most advances truly take place. It is a story about making many small improvements in patients' treatment and care. It is a story of how each new step builds on the one before until their combined power starts to prolong lives or at least improve the quality of life that remains. It is the story, unheralded by headlines, of growing progress in the treatment of AIDS.

Drugs such as AZT and ddI offer some temporary firepower against the HIV virus. In February, a medical student at Massachusetts General Hospital in Boston reported that adding a third drug, pyridinone, to the medicinal fusillade obliterates the virus, but that test-tube result remains to be duplicated in humans. Most of the progress has come from the prevention and treatment of the dangerous secondary infections that are the hallmark of AIDS.

The first indication that the disease could be tamed if not cured came in 1987, when physicians discovered how to prevent pneumocystis pneumonia, a secondary infection of the lungs that caused one-third of AIDS deaths. At the + time, pneumocystis was treated with a drug called pentamidine, which was given intravenously. Thanks to the efforts of a network of doctors organized by the American Foundation for AIDS Research, clinicians learned that, when the drug was sprayed into the lungs, it dramatically reduced the recurrence of the disease. In addition, lab tests can now predict who is at risk for developing pneumocystis, and physicians have found that an antibiotic marketed under the names Bactrim and Septra is effective in preventing the infection.

Clinicians have also achieved some success against a lung ailment called Mycobacterium avium complex, which mimics tuberculosis. "MAC is difficult to treat," says Dr. Mathilde Krim, chairman of AmFAR. "It is considered a bad omen and is usually terminal." This past December the Food and Drug Administration approved rifabutin for protection against MAC. According to clinical trials sponsored by AmFAR, the drug cuts the chance of developing MAC 65%.

In the future, nutritionists are likely to play an important role on the aids medical team. AIDS, like cancer, often causes people to lose their appetite, which worsens their medical condition. So eating the right foods could be crucial. Some patients may be helped by taking Marinol, a synthetic form of the active ingredient in marijuana, which restores appetite.

One of the most feared complications of AIDS is its ability to attack the nervous system. Sometimes HIV infects the brain, causing memory loss and other problems. This condition can be treated in children with AZT because the antiviral drug manages to penetrate the cellular barrier that protects the brain. In adults who develop dementia, higher doses are required and may be only partially effective.

Even when HIV does not affect the nervous system, other parasites, like the protozoan that causes toxoplasmosis, can create similar problems. Many people are host to this one-celled creature with no ill effects. It is only after the immune system breaks down that the parasite proves dangerous. An increasingly common inflammation of the brain, "toxo" is now being treated with pyrimethamine in combination with sulfadiazine or injections of clindamycin. Moreover, the condition can be prevented by Bactrim.

The progress against cryptococcal meningitis, a fungal infection of the brain, has been especially striking. In the beginning, treatment consisted of high doses of intravenous amphotericin B, which patients quickly dubbed "amphoterrible" because of its nauseating side effects. Since then, most of the unpleasantness has been eliminated by lowering the dose, giving it for shorter periods of time and then following it with fluconazole, which can be taken orally. While the treatment controls cryptococcus, it does not eliminate the bug completely, and patients must take fluconazole for the rest of their life.

Still needed: greater success against cytomegalovirus. When it strikes the intestines, it causes painful diarrhea and must be treated with two intravenous drugs, ganciclovir and foscarnet. Researchers hope they can develop effective oral forms of these drugs. Unfortunately, CMV is harder to control if it spreads to the eyes, where it can cause blindness.

Though a cure for AIDS is not at hand, treatment has come a long way since the early days of the epidemic. Says Dr. Paul Volberding of the University of California at San Francisco: "There is no doubt that we're keeping people living longer and with very reasonable quality of life."