Cocktail Time

New U.S. guidelines suggest that powerful anti-viral drug combinations should be used later, rather than earlier, in treating AIDS

According to the new guidelines, patients should not get "triple therapy" -- a protease inhibitor and two older anti-HIV drugs -- until the number of T-helper immune cells falls to fewer than 350 per milliliter of blood. The normal level is around 800. Older guidelines advise that triple therapy treatment should begin when T-helper cell levels fall to 500 per milliliter of blood.

"It's pretty much of a sea change," says Mark Harrington, senior policy director for Treatment Action Group, a New York-based advocacy organization.

"It's an accumulation of all the side effects we've seen," says Volberding, who's on the government committee that wrote the new federal guidelines. "There were neuropathologies, some suppression of red blood cells that would cause anemia. There were some drugs that caused kidney stones or skin rashes. There are a number of potential side effects, but it's not as if those are so horrendous we can't work with them; we do. But we recognize we don't need to use the medicines as early as we thought."

For San Francisco physicians at the forefront of global AIDS treatment, the new guidelines will come as no surprise, says Martin Delaney, founding director of Project Inform, an S.F. AIDS information advocacy group. Here, doctors, researchers, activists, and patient groups join in a constantly evolving debate about treatment strategies. The result has been an amalgam of the latest science and current understandings of patient needs. With the goal of a cure out of reach, medicine now seeks the best possible compromise between disease control and quality of life.

"A lot of doctors in San Francisco have backtracked, and are withholding treatment until much later, and there's sentiment with the patients not to start until much later," says Delaney, who is also a member of the government committee that drafted the new guidelines.

New medical technologies allow doctors to closely monitor the amount of virus in a patient's bloodstream, so there's less danger in waiting to battle the disease with drug cocktails. New knowledge about the immune system's ability to recover following a battle with HIV has also allowed doctors to postpone drug treatment. The new AIDS thinking isn't all the result of bad news -- the fact that the protease-inhibitor-based cocktails have proved effective has allowed doctors to employ the drugs later in the game, confident that they will still have a strong chance of beating back HIV.

But the new government advice may come as a surprise to doctors unversed in the latest in AIDS research, Delaney says.

The hit-early, hit-hard idea found a ready audience with doctors who felt humbled by this baffling disease, doctors and activists tell me. Doctors, like other human beings, are wont to prefer action to inaction. And Dr. Ho's early research results, combined with the hopeful period that followed, may have led some of these physicians to be too hasty with toxic AIDS cocktails, AIDS activists are now saying.

By the time Ho's early findings were washed through endless media reports and misstatements in community newsletters, the message was delivered that everybody infected with HIV should be on multidrug treatment -- but there was never any data to support that notion, Delaney says. "It was how the interpretation sifted through the culture. Doctors picked up on the culture rather than the science," he says. "There were a lot of people who went on treatment too early, before there was any evidence that you could help them."

But that experience has informed a new way of thinking about AIDS. Now, patients infected with AIDS will suffer less and have a better chance at survival. That's medicine. That's culture. And that's AIDS.

A Newspaper to Root for

Perhaps the saddest thing about the ongoing Fang-Examiner-Hearst train wreck is that, given any other circumstances, the Ex kids would be just the kind of people we'd root for.

A feisty, independently owned local newspaper, recently acquired by a gay entrepreneur, making a go of it against impossible odds. Ordinarily, these words would evoke golden moments in other spheres: the 1980 U.S. Hockey Team victory, or the scene in Porky's when Angel Beach High wins the state basketball championship. But when you add the words "political patronage," "multimillion-dollar power play," and "sleaze, sleaze, sleaze," the Examiner fandango sadly loses the je ne sais quoi that arouses the underdog fan club.

So we were very excited to learn about the otherfeisty local newspaper recently acquired by S.F. gay entrepreneurs who want to make a go of it against impossible odds. That would be the Comstock Chronicle of Virginia City, Nev., reopening this week under the ownership of longtime San Francisco artists Kristen Bachler and Betty Kaplowitz.

"We really thought that the paper shouldn't die, that the area needed a good paper, and that we had the insanity or wherewithal to build it into a good paper," says Bachler, a resident of the Western Addition for 11 years.

"We want to keep the sense of humor that papers along the Comstock area have had, including Mark Twain, who used to make up stories, which we aren't going to do," says Kaplowitz, referring to Samuel Clemens' hijinks during his two years at the now-defunct Territorial Enterprise, the Chronicle's Virginia City predecessor, which closed in 1916, was revived in 1952, and was shuttered again in 1969.

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