rock%lighthouse%pyrdc%wubios@uunet.UU.NET (Roger Rock Rosner) (10/29/89)
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EDUCATION/SERVICES - Table of Contents February 1989 - Vol 1, No 2
The Numbers Game
Corrections
Options+ discusses HIV
Book Review: "AIDS: Second Edition"
AZT may cause vitamin B12 deficiency
Pharmacy offers HIV-related drugs at wholesale prices
Dental Clinic available
Healthway offers discount
"Shortcuts:" How to get a handicapped parking permit
Aerosolized pentamidine clinic begins
LifeLink will benefit from Romanovsky & Phillips concert
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THE NUMBERS GAME
What's in a number? Every day, we are surrounded with numbers: driver's
license number, social security number, lots of phone numbers, and so on.
These days, the most frightening and most confusing numbers are the ones we
get back from our doctors. What does it mean if my T4 cells are at 452 per
cubic millimeter? Should I care if my helper/suppressor ratio is 0.2? Is a
lymphocyte count of more than 2,000 good or bad? In this article, we'll
attempt to answer some of the questions about The Numbers Game.
A lot of the furor over T4 counts has been exaggerated. You will quickly
discover that there are no absolutes when it comes to HIV. Some doctors
will tell you that T4 counts of less than 500 mean you should take AZT;
others will want to wait until the count drops below 200. Some people have
become diagnosed with full-blown AIDS with T4 cell counts of greater than
500; others have lived for years, without getting any of the major
opportunistic infections, with T4 cell counts in the teens and twenties.
Another problem is that there are considerable variations in results even
between different labs, and that for many labs these tests are not well
standardized.* Some past protocols were famous for having every
participating hospital across the country send their blood samples to the
same lab on the west coast, and that lab always had counts 50 to 100
cells/mm^3 lower than local labs.
What exactly do all these numbers mean? Let's look at each of them
individually.
------------------------------
WHITE BLOOD CELLS (WBC)
Normal value: 4,000 - 10,000 per cubic millimeter
There are several different types of white blood cells. They are produced
by your bone marrow and lymphoid tissues (your lymph glands, with the most
easily identified ones located around your neck, under your armpits, and
around your groin). White blood cells play a vital role in your immune
system, because they are the soldiers that destroy invading cells, viruses,
and organisms. People with AIDS often have a lowered WBC count.
White blood cells can be divided into two major varieties: agranular and
granular. Agranular cells include the small, medium and large lymphocytes
and the monocyte, which together account for approximately 20 to 25 percent
of the White Blood cells.
The granular cells, also known as leukocytes, are of three types:
neutrophils, eosinophils, and basophils.
------------------------------
LYMPHOCYTES (LYMPHS)
Normal value: 1,000 - 3,000 per cubic millimeter
Lymphocytes are a type of white blood cell, and they are among the most
important cells affected by HIV. These are the cells responsible for
identifying foreign invaders (antigens) as being "non-self," or not part of
your body's normal make-up. They then stimulate the destruction and
elimination of the antigen (sound the alarm and call for the troops). Two
major classes of lymphocytes are the T and the B lymphocytes.
------------------------------
T4 CELLS
Normal value: approximately 600 - 1200 per cubic millimeter
Your T-lymphocytes are a family of cells which play a vital role in your
immune system. The T-lymphocytes do not produce antibodies, but they
control the cells which do by sending out chemical messages. The T4 cells
(also called "helper/inducer cells") act like a security guard who calls the
cops when it detects intruders. The T4 cells cause your immune system to
start attacking invading viruses, parasites, tumors, and fungi. HIV
interferes with your T4 cells by taking them over and using their chemical
components to reproduce (like "Invasion of the Body Snatchers"), by binding
groups of T4 cells together into a big, useless clump called syncytia, and
by bursting T4 cells during a blowout burst of reproduction (see "A Layman's
Guide to HIV" in the December, 1988 issue). By rendering your T4 cells
ineffective, or just outright destroying them, HIV interferes with your
immune system and leaves you open to opportunistic infections (like blind-
folding or killing the security guard so you can rob the museum).
There is a wide variation in the individual response of your T4 cells to
HIV, and exactly what your T4 counts mean is very unclear. However, studies
have shown that 43 percent of people with less than 300 T4 cells per cubic
millimeter developed AIDS over a three-year study period, compared with five
percent of people with over 550 T4 cells/mm^3. The Walter Reed staging
system for tracking HIV infection uses a criteria of fewer than 400 T4
cells/mm^3 as a significant indicator of the state of your immune system;
other research shows that patients with T4 counts of less than 150
cells/mm^3 are at substantially higher risk for developing full-blown AIDS.
Recent research seems to indicate that it is the trend of your T4 cell
counts--steady, increasing, declining, or sharply declining--that is a
better measure of the state of your immune system than the absolute count
value of cells per cubic millimeter. This is yet another reason why ongoing
monitoring of your health is important.
As stated above, there is a lot of debate about exactly what having a
certain number of T4 cells means. It is important to keep in mind that it
is your overall health and immune system status which is really important--
the numbers can go hang. If your numbers are low but you aren't sick, don't
panic. Similarly, just because your numbers are high doesn't necessarily
mean that you can sit complacent. A long talk with your doctor about your
OVERALL state of health, the result of evaluating a lot of different tests,
not just your T4 counts, is much more informative. Between you and your
doctor, you can plan a strategy for your total health care.
------------------------------
T8 CELLS
Normal value: approximately 150 - 600 per cubic millimeter
While the T4 cells scream for the cops to kill the invaders, the T8 cells
(also called "suppressor/cytotoxic cells") act to reverse the process. They
calm things down in your body after the T4 cells get things jumping. These
cells also kill tumor cells, and kill cells infected with viruses.
The normal ratio in your body of T4 "helper" cells to T8 "suppressor" cells
is about 2:1 (2.0). After devastation of your T4 "helper" cells by HIV,
however, that ratio can change radically in the other direction, to about
1:5 (0.2) or worse. This also helps explain why your immune system gets
destroyed by HIV: with reduced numbers of T4 "helper" cells, but normal
numbers of T8 "suppressor" cells, your immune system is told to stop working
by the T8 cells before it ever receives the message to get going from the T4
cells.
------------------------------
B LYMPHOCYTES
Normal Immunoglobin values:
IgG: 650 - 1600 milligrams per decaliter
IgA: 65 - 415 milligrams per decaliter
B lymphocytes are the cells that produce substances called antibodies. Each
antibody exactly matches a specific antigen (foreign cell component), much
like a specific key fits a specific lock. (Think of assassins, each with
their own specific target to kill.) There are five classes of antibodies,
which are also known as immunoglobulins. Each class has a different role in
the immune defense system, and they have names like IgG, IgM, and IgA. It
has been found that the levels of IgG and IgA are elevated in people with
AIDS. Why this happens remains a mystery, although it is might be due to
faulty regulation of antibody production by the B cells.
------------------------------
NATURAL KILLER CELLS (NK CELLS)
Normal value: greater than 50 lytic units per 10 million cells
Natural killer cells are a type of lymphocyte that attack and destroy tumor
cells and cells that have been infected by viruses. They are called
"natural" killers because they go into action without additional stimulation
(unlike other cells, which require your T4 cells to signal that they should
do something). People with AIDS usually have decreased activity of NK
cells. The cells often fail to react without stimulation, although their
numbers may be normal. Some researchers are trying to use interferons
(alpha, beta, gamma, etc.) to stimulate the activity of the NK cells in an
attempt to overcome whatever portion of HIV infection is inhibiting them,
and return them to their normal attack mode.
------------------------------
POLYMORPHONUCLEAR CELLS (POLYS OR NEUTROPHILS)
Normal value: 2,500 - 5,000 per cubic millimeter
Polys are mature white blood cells that eat bacteria and foreign matter in
your blood. Neutrophils make up 40 to 80 percent of the leukocytes in your
blood. When your total poly count is less than 500 per cubic millimeter,
you are at an increased risk for bacterial and certain fungal infections.
Although AIDS patients usually have a normal poly count, some medications
given to fight HIV can cause a decrease in your poly count.
------------------------------
LIVER ENZYMES
Normal value:SGOT: 0 - 50 units per ml
SGPT: 0 - 50 units per ml
Measuring the enzymes that are in your blood which are produced by your
liver is a way of measuring how well your liver is working. If your liver
enzymes (two such enzymes are SGOT and SGPT) are elevated, it means that
your liver function is impaired. If the impairment is severe, you could be
in serious risk of liver failure. Your liver is responsible for cleaning
out the blood--removing the impurities and harmful substances.
There are many reasons your liver function could be having problems:
viruses (like Hepatitis A, Hepatitis B, Hepatitis non-A-non-B, Epstein-Barr
Virus, Cytomegalovirus, etc.), chemicals, bacteria, drugs (both legal and
illegal), and alcohol. Hepatitis is an inflammation of the liver, which can
inhibit its ability to function. If serious enough, you can start to become
jaundiced (which means your skin and eyes turn yellow). Alcohol has a very
adverse effect on the liver, both because it is poisonous to your liver, and
because it can cause a build up of fatty deposits within the liver, reducing
the capacity of the liver to process your blood. Every year, there are
approximately 4,500 deaths in the United States due to alcohol-induced
cirrhosis of the liver (a condition in which the normal liver tissue is
replaced by useless scar tissue). Drinking alcohol while you are recovering
from any form of hepatitis is a real recipe for trouble.
------------------------------
ERYTHROCYTES
Normal value:
Adult Men: 5,000,000 per cubic millimeter
Adult Women: 4,500,000 per cubic millimeter
Erythrocytes are your red blood cells. They contain hemoglobin, which is
what gives your blood its characteristic red color, and is also what carries
oxygen from your lungs out to the cells in your body that need it, and
carbon dioxide back to your lungs. If your erythrocyte count is markedly
decreased, you are anemic. Severe anemia causes people to look pale and
have a pasty complexion. Transfusions are often given to people to help
counteract anemia. AZT and some other medications used to fight HIV can
also cause reductions in the erythrocyte counts, as can internal bleeding.
------------------------------
PLATELETS
Normal value: 140,000 - 440,000 per cubic millimeter
Platelets are small irregular bodies that exist in large numbers in your
blood. They are not actually cells, but are cell fragments that originate
in your bone marrow and then break off to float around in your blood.
Platelets change their shape and weave together tiny fibers to form clots
when your blood vessels are injured or become exposed. A low platelet count
could cause your blood to have difficulty clotting. (Note that clotting is
an extremely complex process, requiring a very esoteric sequence of events
to happen in an exact manner. Many other things, including a deficiency in
Vitamin K or a coagulation disorder like hemophilia, can also cause problems
with the clotting process.)
------------------------------
p24 ANTIGEN
Normal value: 0, not present
Much debate has raged over the usefulness of the p24 antigen test. p24 is
one of the core proteins surrounding the RNA strands at the heart of HIV.
If there are detectable amounts of p24 in your blood, it seems to mean that
there is HIV active in your blood, too. The latest research guess is that
patients show a high level of p24 right after infection, and then low or
unmeasurable levels of p24 while HIV is in its dormant stage. The
researchers believe that if high levels of p24 occur again, it is a signal
that HIV has begun active replication in high numbers, and is indicative
that the person may get full-blown AIDS within a short time.
------------------------------
PHYTOHEMMAGLUTININ (PHA)
Normal response by T4 cells in the test tube: greater than 20,000 counts
per minute
PHA is a "mitogen," a substance which stimulates the division of a
lymphocyte to form two new lymphocytes. It is used to measure a non-
specific response of all T cells in a test tube to determine how well your
overall immune system is doing. A person with AIDS usually has a decreased
response due to a decreased number of T cells.
------------------------------
TETANUS TOXOID (TT)
Normal response by T4 cells in the test tube: greater than 5,000 counts per
minute
Tetanus toxoid is an antigen (foreign substance) used to measure the
response of your T4 cells to it specifically in the test tube. Most people
have had tetanus immunizations (remember your mother threatening that you
would get lock-jaw if you didn't have a tetanus booster after stepping on a
nail on the playground?), so your T4 cells should recognize TT as an antigen
and stimulate an immune response. The T4 cells of a person with AIDS lose
their ability to function in this manner.
Another way of testing for a response to TT is to inject a tiny amount just
under the skin of the upper arm (this is called an intradermal injection).
This pushes the skin up, producing a round, slightly raised area. The
response of a person with a normal immune system is a reddened hard spot
which appears within 48 hours. Most people with AIDS do not show a
response.
------------------------------
While test results are important, and are giving us valuable insight into
the course of HIV infection, they are neither infallible nor absolute. The
methods used to collect results are subject to errors, and we still have
much to learn about their meaning.
In consultation with your doctor, test results should be used to help you
decide what your course of action for pursuing treatment should be. Bear in
mind, however, that low scores are not a guarantee of swift death, and
neither are high scores grounds for indefinite complacency.
------------------------------
Much of the material contained in this article was derived from material
supplied by the National Institutes of Health/National Institute of Allergy
and Infectious Diseases, Laboratory of Immunoregulation. Grateful
acknowledgment is made of both their permission to use their material, and
their assistance in reviewing this article for accuracy.
------------------------------
NOTES:
* On the other hand, there are research labs with well-developed standards,
who report accurate, reproducible cell counts, and use these counts as part
of a "staging system" to indicate the progression of HIV disease. Notable
among these labs is the Walter Reed Army Institute of Research, which has
developed the Walter Reed Staging System.
------------------------------
REFERENCES:
AIDS: Etiology, Diagnosis, Treatment, and Prevention (Second Edition).
Vincent T. DeVita, Jr., Samuel Hellman, and Steven A. Rosenberg, Editors.
J.B. Lippincott Company, Philadelphia, Pennsylvania. 1988. Pages 48-50,
112-117, 216-217.
McGraw-Hill Encyclopedia of Science & Technology (Sixth Edition), Volume 2.
McGraw-Hill Book Company, New York, NY. Pages 620-631.
"Bodily Harm: The Health Effects of Excessive Drinking" by Evelyn Zamula.
FDA Consumer, May 1986.
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CORRECTIONS
In "A Layman's Guide to HIV" (December, 1988), a few things were incorrect.
The article implied that an individual HIV is a single strand of RNA
surrounded by proteins; actually the HIV consists of two identical strands
of RNA surrounded by proteins. The first sidebar explanation of DNA
replication on page three is correct, stating that the pairing of bases is
such that adenosine will only bind with thymidine, and cytosine will only
bind with guanine. The second time DNA replication is mentioned on page
five, the article stated that adenosine will only bind with cytosine, and
thymidine will only bind with guanine. This is incorrect, as are the bases
labeled inside the figures.
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OPTIONS+ DISCUSSES ALTERNATIVES
OPTIONS+, the HIV alternatives group, meets monthly to discuss aspects of
HIV infection, provide mutual emotional support, and to provide a relaxed
social outlet for people with HIV.
The next meeting will be on Thursday, February 16th, and will discuss
different people's experiences undergoing drug testing protocols. The
following meeting will be on Thursday, March 16th, and will focus on
macrobiotics. Both meetings will be held at St. John's Lafayette Square
Church, 1525 H Street, N.W. (take the McPherson Square Metro stop, White
House exit). The meetings run from 7:30 p.m. to approximately 9:00 p.m.
For more information, please call 229-0882 (evenings).
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BOOK REVIEW
"AIDS: Etiology, Diagnosis, Treatment and Prevention (Second Edition)."
Edited by Vincent T. DeVita, Jr., Samuel Hellman, and Steven A. Rosenberg.
Reviewed by W. Howard Cyr
This is by far the most complete treatment of AIDS from a scientific,
clinical, and public health view point. For the most part, this large
(nearly 500 pages) book is a medical text, but one that is surprisingly easy
to read. All of the most well known researchers in the United States are
authors, which include 57 scientists, practitioners, epidemiologists, and
others involved in studying HIV or in providing care to patients with HIV
disease. There are two foreign authors, Dr. Lurhuma from Zaire and Dr.
Daniel Zagury of France, who worked together on a vaccine for HIV.
There are twenty-eight chapters broken down into three major parts, one
dealing with the structure and genetics of the virus, one with HIV disease
and the different therapeutic options, and the last dealing with public
health concerns of disease transmission and prevention. This thorough
treatment of AIDS has been edited by Drs. DeVita and Rosenberg, both
associated with the National Cancer Institute of NIH, and by Dr. Hellman of
the University of Chicago. The charts, graphs, and diagrams are clear and
add significantly to each chapter. The book is copyrighted in 1988, but
some of the chapters were finished in late 1987, as evidenced by the data
shown for numbers of cases of AIDS.
I have to admit that the first part on virology does not have the
beautifully illustrated pictures and diagrams that are found in the October
issue of Scientific American, and people who are interested in only that
part of AIDS or HIV would probably do well to stick to that resource. But
this book goes far beyond the subject matter covered in the Scientific
American articles, particularly with its in-depth coverage of testing
(Elisa, Western blots, PCR, etc.), opportunistic infections, neurological
complications, Kaposi's sarcoma, drug treatments, vaccine development, and
AIDS in different groups (Gay men, pediatric cases, Africans, intravenous
drug users, heterosexuals, etc.).
Several of my colleagues have examined this text and agree that it is the
best single source of information on the various aspects of AIDS. Even
those who are not rigorously trained in biological sciences have found this
text readable, although some chapters are more so than others. Again, those
chapters dealing with the structure and genetic control of HIV tend to be
the most difficult, and for some may be impossible.
For those in research, in medical practice, and in AIDS education, this is a
most valuable text. For those less trained, I suggest spending some time
looking at the book before investing in it. On the negative side, this is
an expensive text, costing about $52.00 and it is not readily available at
your nearby bookstore. I purchased mine at the NIH bookstore, located in
the Clinical Center (Building 10) on the NIH campus. (I have not checked to
see if this book is available at other university bookstores, such as the
bookstore in the student center at George Washington University.) The book
is published by the J.B. Lippincott Company of Philadelphia.
------------------------------
W. Howard Cyr has a Ph.D. in biophysics, is a commissioned officer of the
Public Health Service, and is the AIDS Coordinator for the Office of Science
and Technology of the Center for Devices and Radiological Health of the Food
and Drug Administration.
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****************************************************************************
AZT MAY CAUSE VITAMIN B12 DEFICIENCY
Scientists from the National Institutes of Health and the University of
Miami reported in the New England Journal of Medicine and Lancet that
patients who are taking AZT often show signs of vitamin B12 and folic acid
defiencies. It is recommended that anyone who is taking AZT have his or her
doctor monitor B12 and folic acid levels, and consider taking supplements,
either orally or through shots.
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PHARMACY OFFERS DRUGS AT WHOLESALE PRICES
The Whitman-Walker Clinic recently opened a pharmacy which provides services
to all persons who are HIV positive. The pharmacy can fill prescriptions
for medications used to treat HIV-related conditions. The pharmacy cannot
fill prescriptions for controlled substances such as pain medications.
The pharmacy is open on Tuesday and Thursday evenings from 6:00 - 9:00 p.m.
Your primary physician must telephone in your prescription at 483-1726
before your prescription can be filled.
The costs for medications are set at the prevailing wholesale prices.
Because of this, prices may fluctuate. Some drugs offered through the
pharmacy are available at a significantly lower price than those available
through commercial pharmacies.
Payment for medication must be in the form of cash, credit cards (VISA,
MasterCard, American Express), or personal checks in small amounts. No
third-party payments will be accepted.
In order to use the pharmacy, a person must:
1. be HIV positive;
2. have a physician call in the prescription at 483-1726;
3. be able to pay for medication in cash or by credit card or personal
check;
4. be able to pick up prescriptions during pharmacy hours.
For more information, contact the Whitman-Walker Clinic's Medical Services
department at 797-3530.
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DENTAL CLINIC AVAILABLE TO PEOPLE WITH AIDS AND ARC
The Whitman-Walker Dental Clinic provides treatment to people who are HIV
positive and who are having difficulty obtaining dental services from
outside dentists or who are unable to pay for outside dental services.
The Dental Clinic is open, by appointment only, on Mondays from 1:00 - 5:00
p.m., Wednesdays 6:00 - 8:30 p.m., and Fridays 9:00 a.m. - 12:00 p.m.
Preference is given to PWAs and emergencies. The clinic is unable to
provide crowns or denture services. There is no limit to the number of
visits.
There is no charge for services; however, donations are suggested. The
suggested donation amounts vary depending on the type of services provided.
In order to receive dental services you must be HIV positive or have an AIDS
or ARC diagnosis, and make an appointment by either coming in and speaking
with the medical receptionist or by calling 797-3533.
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HEALTHWAY OFFERS DISCOUNT
Healthway, a health and natural food store with five branches in Northern
Virginia, is offering a 25 percent discount on vitamins to people who are
HIV infected. Healthway features vitamins, natural organic foods, fresh
organic produce, dried fruit, natural cosmetics and body care products,
natural remedies, natural versions of snacks, rices, grains, frozen dinners,
vegetables, spring water, bulk foods, and many other items.
For more information, ask for the store manager (Wally at Arlington, Cheryl
at Annandale, Melinda at Fairfax, Marcy at Springfield, or Gretchen at
Manassas) or call Cheryl at 354-7782.
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SHORTCUTS
How to get a handicapped parking permit
Washington, Maryland, and Virginia all make parking permits available to
handicapped persons. There are two types of permits which allow parking in
spaces restricted to handicapped individuals. One is a permit for those
who, due to their handicap, cannot drive. This permit is for use by the
person providing transportation to the handicapped individual. The other
permit is for use by an individual who is handicapped, but can drive.
In order to obtain a permit, the handicapped person should contact the
Division of Motor Vehicles (DMV) which serves the area in which he/she
lives. That office will send the necessary application form to their home.
The form can also be obtained in person at the DMV. The application
requires identifying information on the applicant, as well as a signed
statement from his/her physician which verifies that the applicant has a
condition which warrants obtaining the permit. The completed form must be
returned to the DMV, which will issue the appropriate permit.
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AEROSOLIZED PENTAMIDINE CLINIC BEGINS
The Whitman-Walker Clinic recently announced the formation of a clinic for
the administration of aerosolized pentamidine. Note that they are not
providing the pentamidine itself (although it can be obtained through the
Clinic pharmacy), but are providing the machinery (called nebulizers) which
turns the pentamidine into a fine mist which can then be inhaled. Inhaled
pentamidine has been shown to be very effective in preventing the recurrence
of pneumocystis pneumonia.
Nebulizers are fairly expensive (several hundred dollars each), so this
clinic provides a low-cost or no-cost basis for people to receive
prophalaxis (preventative measures) against pneumocystis cariini pneumonia.
However, as the clinic is only able to provide services to a total of 48
patients, participation in the clinic is limited to individuals who have
already had one episode of pneumocystis pneumonia or who have T4 counts
below 200.
The clinic is open, by appointment only, on Tuesdays and Thursdays from 9:00
a.m. - 12:00 noon. There is no charge for treatment; however, a donation of
$10 per visit is suggested.
In order to receive pentamidine treatment at the clinic you must:
1. have had one episode of pneumocystis pneumonia or have a T4 count below
200;
2. have a written referral from your physician addressed to the Whitman-
Walker Clinic, requesting pentamidine treatment;
3. provide your own pentamidine (the clinic will aerosolize it and provide
administration);
4. contact the clinic to schedule an appointment for treatment by calling
797-3533.
If you have any questions, you can contact Dr. Basil Vareldzis at 797-3534.
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LIFELINK WILL BENEFIT FROM ROMANOVSKY & PHILLIPS CONCERT
The George Washington University Lesbian and Gay People's Alliance and
Program Board are presenting Romanovsky & Phillips in concert on Sunday,
March 19th, at the Dorothy Betts Marvin Theatre at G.W., located at 800 21st
Street, N.W., Washington, D.C. Romanovsky & Phillips have been described as
a "gay Smothers Brothers," with music ranging from folk to comedy to
ballads. Their unique style encompasses everything from do-wop to reggae.
Proceeds from the concert will benefit LifeLink, the D.C. Coalition of
People with AIDS. Ticket prices are $7.00 in advance and $11.00 at the door
for G.W. students, and $10.00 in advance and $14.00 at the door for everyone
else. Tickets are available at Lambda Rising, both branches of Lammas, the
G.W. Marvin Center, and the House of Musical Traditions in Takoma Park. For
more information or reservations, call 994-7590.
***************************************************************************
Copyright (C) 1988,1989 by Washington HIV News, all rights reserved.
Permission is granted for non-commercial use only.phil@wubios.WUstl.EDU (J. Philip Miller) (11/12/89)
Forwarded message:
>From pyrdc!lighthouse!rock@uunet.UU.NET Tue Oct 24 19:13:38 1989
Date: Tue, 24 Oct 89 18:55:18 GMT-0500
From: pyrdc!lighthouse!rock@uunet.UU.NET (Roger Rock Rosner)
Message-Id: <8910242355.AA01227@ lighthouse >
To: phil@wubios, ddodell@stjhmc.fidonet.org
Subject: Washington HIV News: V1N2, 2/3
***************************************************************************
EDUCATION/SERVICES - Table of Contents February 1989 - Vol 1, No 2
The Numbers Game
Corrections
Options+ discusses HIV
Book Review: "AIDS: Second Edition"
AZT may cause vitamin B12 deficiency
Pharmacy offers HIV-related drugs at wholesale prices
Dental Clinic available
Healthway offers discount
"Shortcuts:" How to get a handicapped parking permit
Aerosolized pentamidine clinic begins
LifeLink will benefit from Romanovsky & Phillips concert
***************************************************************************
THE NUMBERS GAME
What's in a number? Every day, we are surrounded with numbers: driver's
license number, social security number, lots of phone numbers, and so on.
These days, the most frightening and most confusing numbers are the ones we
get back from our doctors. What does it mean if my T4 cells are at 452 per
cubic millimeter? Should I care if my helper/suppressor ratio is 0.2? Is a
lymphocyte count of more than 2,000 good or bad? In this article, we'll
attempt to answer some of the questions about The Numbers Game.
A lot of the furor over T4 counts has been exaggerated. You will quickly
discover that there are no absolutes when it comes to HIV. Some doctors
will tell you that T4 counts of less than 500 mean you should take AZT;
others will want to wait until the count drops below 200. Some people have
become diagnosed with full-blown AIDS with T4 cell counts of greater than
500; others have lived for years, without getting any of the major
opportunistic infections, with T4 cell counts in the teens and twenties.
Another problem is that there are considerable variations in results even
between different labs, and that for many labs these tests are not well
standardized.* Some past protocols were famous for having every
participating hospital across the country send their blood samples to the
same lab on the west coast, and that lab always had counts 50 to 100
cells/mm^3 lower than local labs.
What exactly do all these numbers mean? Let's look at each of them
individually.
------------------------------
WHITE BLOOD CELLS (WBC)
Normal value: 4,000 - 10,000 per cubic millimeter
There are several different types of white blood cells. They are produced
by your bone marrow and lymphoid tissues (your lymph glands, with the most
easily identified ones located around your neck, under your armpits, and
around your groin). White blood cells play a vital role in your immune
system, because they are the soldiers that destroy invading cells, viruses,
and organisms. People with AIDS often have a lowered WBC count.
White blood cells can be divided into two major varieties: agranular and
granular. Agranular cells include the small, medium and large lymphocytes
and the monocyte, which together account for approximately 20 to 25 percent
of the White Blood cells.
The granular cells, also known as leukocytes, are of three types:
neutrophils, eosinophils, and basophils.
------------------------------
LYMPHOCYTES (LYMPHS)
Normal value: 1,000 - 3,000 per cubic millimeter
Lymphocytes are a type of white blood cell, and they are among the most
important cells affected by HIV. These are the cells responsible for
identifying foreign invaders (antigens) as being "non-self," or not part of
your body's normal make-up. They then stimulate the destruction and
elimination of the antigen (sound the alarm and call for the troops). Two
major classes of lymphocytes are the T and the B lymphocytes.
------------------------------
T4 CELLS
Normal value: approximately 600 - 1200 per cubic millimeter
Your T-lymphocytes are a family of cells which play a vital role in your
immune system. The T-lymphocytes do not produce antibodies, but they
control the cells which do by sending out chemical messages. The T4 cells
(also called "helper/inducer cells") act like a security guard who calls the
cops when it detects intruders. The T4 cells cause your immune system to
start attacking invading viruses, parasites, tumors, and fungi. HIV
interferes with your T4 cells by taking them over and using their chemical
components to reproduce (like "Invasion of the Body Snatchers"), by binding
groups of T4 cells together into a big, useless clump called syncytia, and
by bursting T4 cells during a blowout burst of reproduction (see "A Layman's
Guide to HIV" in the December, 1988 issue). By rendering your T4 cells
ineffective, or just outright destroying them, HIV interferes with your
immune system and leaves you open to opportunistic infections (like blind-
folding or killing the security guard so you can rob the museum).
There is a wide variation in the individual response of your T4 cells to
HIV, and exactly what your T4 counts mean is very unclear. However, studies
have shown that 43 percent of people with less than 300 T4 cells per cubic
millimeter developed AIDS over a three-year study period, compared with five
percent of people with over 550 T4 cells/mm^3. The Walter Reed staging
system for tracking HIV infection uses a criteria of fewer than 400 T4
cells/mm^3 as a significant indicator of the state of your immune system;
other research shows that patients with T4 counts of less than 150
cells/mm^3 are at substantially higher risk for developing full-blown AIDS.
Recent research seems to indicate that it is the trend of your T4 cell
counts--steady, increasing, declining, or sharply declining--that is a
better measure of the state of your immune system than the absolute count
value of cells per cubic millimeter. This is yet another reason why ongoing
monitoring of your health is important.
As stated above, there is a lot of debate about exactly what having a
certain number of T4 cells means. It is important to keep in mind that it
is your overall health and immune system status which is really important--
the numbers can go hang. If your numbers are low but you aren't sick, don't
panic. Similarly, just because your numbers are high doesn't necessarily
mean that you can sit complacent. A long talk with your doctor about your
OVERALL state of health, the result of evaluating a lot of different tests,
not just your T4 counts, is much more informative. Between you and your
doctor, you can plan a strategy for your total health care.
------------------------------
T8 CELLS
Normal value: approximately 150 - 600 per cubic millimeter
While the T4 cells scream for the cops to kill the invaders, the T8 cells
(also called "suppressor/cytotoxic cells") act to reverse the process. They
calm things down in your body after the T4 cells get things jumping. These
cells also kill tumor cells, and kill cells infected with viruses.
The normal ratio in your body of T4 "helper" cells to T8 "suppressor" cells
is about 2:1 (2.0). After devastation of your T4 "helper" cells by HIV,
however, that ratio can change radically in the other direction, to about
1:5 (0.2) or worse. This also helps explain why your immune system gets
destroyed by HIV: with reduced numbers of T4 "helper" cells, but normal
numbers of T8 "suppressor" cells, your immune system is told to stop working
by the T8 cells before it ever receives the message to get going from the T4
cells.
------------------------------
B LYMPHOCYTES
Normal Immunoglobin values:
IgG: 650 - 1600 milligrams per decaliter
IgA: 65 - 415 milligrams per decaliter
B lymphocytes are the cells that produce substances called antibodies. Each
antibody exactly matches a specific antigen (foreign cell component), much
like a specific key fits a specific lock. (Think of assassins, each with
their own specific target to kill.) There are five classes of antibodies,
which are also known as immunoglobulins. Each class has a different role in
the immune defense system, and they have names like IgG, IgM, and IgA. It
has been found that the levels of IgG and IgA are elevated in people with
AIDS. Why this happens remains a mystery, although it is might be due to
faulty regulation of antibody production by the B cells.
------------------------------
NATURAL KILLER CELLS (NK CELLS)
Normal value: greater than 50 lytic units per 10 million cells
Natural killer cells are a type of lymphocyte that attack and destroy tumor
cells and cells that have been infected by viruses. They are called
"natural" killers because they go into action without additional stimulation
(unlike other cells, which require your T4 cells to signal that they should
do something). People with AIDS usually have decreased activity of NK
cells. The cells often fail to react without stimulation, although their
numbers may be normal. Some researchers are trying to use interferons
(alpha, beta, gamma, etc.) to stimulate the activity of the NK cells in an
attempt to overcome whatever portion of HIV infection is inhibiting them,
and return them to their normal attack mode.
------------------------------
POLYMORPHONUCLEAR CELLS (POLYS OR NEUTROPHILS)
Normal value: 2,500 - 5,000 per cubic millimeter
Polys are mature white blood cells that eat bacteria and foreign matter in
your blood. Neutrophils make up 40 to 80 percent of the leukocytes in your
blood. When your total poly count is less than 500 per cubic millimeter,
you are at an increased risk for bacterial and certain fungal infections.
Although AIDS patients usually have a normal poly count, some medications
given to fight HIV can cause a decrease in your poly count.
------------------------------
LIVER ENZYMES
Normal value:SGOT: 0 - 50 units per ml
SGPT: 0 - 50 units per ml
Measuring the enzymes that are in your blood which are produced by your
liver is a way of measuring how well your liver is working. If your liver
enzymes (two such enzymes are SGOT and SGPT) are elevated, it means that
your liver function is impaired. If the impairment is severe, you could be
in serious risk of liver failure. Your liver is responsible for cleaning
out the blood--removing the impurities and harmful substances.
There are many reasons your liver function could be having problems:
viruses (like Hepatitis A, Hepatitis B, Hepatitis non-A-non-B, Epstein-Barr
Virus, Cytomegalovirus, etc.), chemicals, bacteria, drugs (both legal and
illegal), and alcohol. Hepatitis is an inflammation of the liver, which can
inhibit its ability to function. If serious enough, you can start to become
jaundiced (which means your skin and eyes turn yellow). Alcohol has a very
adverse effect on the liver, both because it is poisonous to your liver, and
because it can cause a build up of fatty deposits within the liver, reducing
the capacity of the liver to process your blood. Every year, there are
approximately 4,500 deaths in the United States due to alcohol-induced
cirrhosis of the liver (a condition in which the normal liver tissue is
replaced by useless scar tissue). Drinking alcohol while you are recovering
from any form of hepatitis is a real recipe for trouble.
------------------------------
ERYTHROCYTES
Normal value:
Adult Men: 5,000,000 per cubic millimeter
Adult Women: 4,500,000 per cubic millimeter
Erythrocytes are your red blood cells. They contain hemoglobin, which is
what gives your blood its characteristic red color, and is also what carries
oxygen from your lungs out to the cells in your body that need it, and
carbon dioxide back to your lungs. If your erythrocyte count is markedly
decreased, you are anemic. Severe anemia causes people to look pale and
have a pasty complexion. Transfusions are often given to people to help
counteract anemia. AZT and some other medications used to fight HIV can
also cause reductions in the erythrocyte counts, as can internal bleeding.
------------------------------
PLATELETS
Normal value: 140,000 - 440,000 per cubic millimeter
Platelets are small irregular bodies that exist in large numbers in your
blood. They are not actually cells, but are cell fragments that originate
in your bone marrow and then break off to float around in your blood.
Platelets change their shape and weave together tiny fibers to form clots
when your blood vessels are injured or become exposed. A low platelet count
could cause your blood to have difficulty clotting. (Note that clotting is
an extremely complex process, requiring a very esoteric sequence of events
to happen in an exact manner. Many other things, including a deficiency in
Vitamin K or a coagulation disorder like hemophilia, can also cause problems
with the clotting process.)
------------------------------
p24 ANTIGEN
Normal value: 0, not present
Much debate has raged over the usefulness of the p24 antigen test. p24 is
one of the core proteins surrounding the RNA strands at the heart of HIV.
If there are detectable amounts of p24 in your blood, it seems to mean that
there is HIV active in your blood, too. The latest research guess is that
patients show a high level of p24 right after infection, and then low or
unmeasurable levels of p24 while HIV is in its dormant stage. The
researchers believe that if high levels of p24 occur again, it is a signal
that HIV has begun active replication in high numbers, and is indicative
that the person may get full-blown AIDS within a short time.
------------------------------
PHYTOHEMMAGLUTININ (PHA)
Normal response by T4 cells in the test tube: greater than 20,000 counts
per minute
PHA is a "mitogen," a substance which stimulates the division of a
lymphocyte to form two new lymphocytes. It is used to measure a non-
specific response of all T cells in a test tube to determine how well your
overall immune system is doing. A person with AIDS usually has a decreased
response due to a decreased number of T cells.
------------------------------
TETANUS TOXOID (TT)
Normal response by T4 cells in the test tube: greater than 5,000 counts per
minute
Tetanus toxoid is an antigen (foreign substance) used to measure the
response of your T4 cells to it specifically in the test tube. Most people
have had tetanus immunizations (remember your mother threatening that you
would get lock-jaw if you didn't have a tetanus booster after stepping on a
nail on the playground?), so your T4 cells should recognize TT as an antigen
and stimulate an immune response. The T4 cells of a person with AIDS lose
their ability to function in this manner.
Another way of testing for a response to TT is to inject a tiny amount just
under the skin of the upper arm (this is called an intradermal injection).
This pushes the skin up, producing a round, slightly raised area. The
response of a person with a normal immune system is a reddened hard spot
which appears within 48 hours. Most people with AIDS do not show a
response.
------------------------------
While test results are important, and are giving us valuable insight into
the course of HIV infection, they are neither infallible nor absolute. The
methods used to collect results are subject to errors, and we still have
much to learn about their meaning.
In consultation with your doctor, test results should be used to help you
decide what your course of action for pursuing treatment should be. Bear in
mind, however, that low scores are not a guarantee of swift death, and
neither are high scores grounds for indefinite complacency.
------------------------------
Much of the material contained in this article was derived from material
supplied by the National Institutes of Health/National Institute of Allergy
and Infectious Diseases, Laboratory of Immunoregulation. Grateful
acknowledgment is made of both their permission to use their material, and
their assistance in reviewing this article for accuracy.
------------------------------
NOTES:
* On the other hand, there are research labs with well-developed standards,
who report accurate, reproducible cell counts, and use these counts as part
of a "staging system" to indicate the progression of HIV disease. Notable
among these labs is the Walter Reed Army Institute of Research, which has
developed the Walter Reed Staging System.
------------------------------
REFERENCES:
AIDS: Etiology, Diagnosis, Treatment, and Prevention (Second Edition).
Vincent T. DeVita, Jr., Samuel Hellman, and Steven A. Rosenberg, Editors.
J.B. Lippincott Company, Philadelphia, Pennsylvania. 1988. Pages 48-50,
112-117, 216-217.
McGraw-Hill Encyclopedia of Science & Technology (Sixth Edition), Volume 2.
McGraw-Hill Book Company, New York, NY. Pages 620-631.
"Bodily Harm: The Health Effects of Excessive Drinking" by Evelyn Zamula.
FDA Consumer, May 1986.
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CORRECTIONS
In "A Layman's Guide to HIV" (December, 1988), a few things were incorrect.
The article implied that an individual HIV is a single strand of RNA
surrounded by proteins; actually the HIV consists of two identical strands
of RNA surrounded by proteins. The first sidebar explanation of DNA
replication on page three is correct, stating that the pairing of bases is
such that adenosine will only bind with thymidine, and cytosine will only
bind with guanine. The second time DNA replication is mentioned on page
five, the article stated that adenosine will only bind with cytosine, and
thymidine will only bind with guanine. This is incorrect, as are the bases
labeled inside the figures.
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OPTIONS+ DISCUSSES ALTERNATIVES
OPTIONS+, the HIV alternatives group, meets monthly to discuss aspects of
HIV infection, provide mutual emotional support, and to provide a relaxed
social outlet for people with HIV.
The next meeting will be on Thursday, February 16th, and will discuss
different people's experiences undergoing drug testing protocols. The
following meeting will be on Thursday, March 16th, and will focus on
macrobiotics. Both meetings will be held at St. John's Lafayette Square
Church, 1525 H Street, N.W. (take the McPherson Square Metro stop, White
House exit). The meetings run from 7:30 p.m. to approximately 9:00 p.m.
For more information, please call 229-0882 (evenings).
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BOOK REVIEW
"AIDS: Etiology, Diagnosis, Treatment and Prevention (Second Edition)."
Edited by Vincent T. DeVita, Jr., Samuel Hellman, and Steven A. Rosenberg.
Reviewed by W. Howard Cyr
This is by far the most complete treatment of AIDS from a scientific,
clinical, and public health view point. For the most part, this large
(nearly 500 pages) book is a medical text, but one that is surprisingly easy
to read. All of the most well known researchers in the United States are
authors, which include 57 scientists, practitioners, epidemiologists, and
others involved in studying HIV or in providing care to patients with HIV
disease. There are two foreign authors, Dr. Lurhuma from Zaire and Dr.
Daniel Zagury of France, who worked together on a vaccine for HIV.
There are twenty-eight chapters broken down into three major parts, one
dealing with the structure and genetics of the virus, one with HIV disease
and the different therapeutic options, and the last dealing with public
health concerns of disease transmission and prevention. This thorough
treatment of AIDS has been edited by Drs. DeVita and Rosenberg, both
associated with the National Cancer Institute of NIH, and by Dr. Hellman of
the University of Chicago. The charts, graphs, and diagrams are clear and
add significantly to each chapter. The book is copyrighted in 1988, but
some of the chapters were finished in late 1987, as evidenced by the data
shown for numbers of cases of AIDS.
I have to admit that the first part on virology does not have the
beautifully illustrated pictures and diagrams that are found in the October
issue of Scientific American, and people who are interested in only that
part of AIDS or HIV would probably do well to stick to that resource. But
this book goes far beyond the subject matter covered in the Scientific
American articles, particularly with its in-depth coverage of testing
(Elisa, Western blots, PCR, etc.), opportunistic infections, neurological
complications, Kaposi's sarcoma, drug treatments, vaccine development, and
AIDS in different groups (Gay men, pediatric cases, Africans, intravenous
drug users, heterosexuals, etc.).
Several of my colleagues have examined this text and agree that it is the
best single source of information on the various aspects of AIDS. Even
those who are not rigorously trained in biological sciences have found this
text readable, although some chapters are more so than others. Again, those
chapters dealing with the structure and genetic control of HIV tend to be
the most difficult, and for some may be impossible.
For those in research, in medical practice, and in AIDS education, this is a
most valuable text. For those less trained, I suggest spending some time
looking at the book before investing in it. On the negative side, this is
an expensive text, costing about $52.00 and it is not readily available at
your nearby bookstore. I purchased mine at the NIH bookstore, located in
the Clinical Center (Building 10) on the NIH campus. (I have not checked to
see if this book is available at other university bookstores, such as the
bookstore in the student center at George Washington University.) The book
is published by the J.B. Lippincott Company of Philadelphia.
------------------------------
W. Howard Cyr has a Ph.D. in biophysics, is a commissioned officer of the
Public Health Service, and is the AIDS Coordinator for the Office of Science
and Technology of the Center for Devices and Radiological Health of the Food
and Drug Administration.
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AZT MAY CAUSE VITAMIN B12 DEFICIENCY
Scientists from the National Institutes of Health and the University of
Miami reported in the New England Journal of Medicine and Lancet that
patients who are taking AZT often show signs of vitamin B12 and folic acid
defiencies. It is recommended that anyone who is taking AZT have his or her
doctor monitor B12 and folic acid levels, and consider taking supplements,
either orally or through shots.
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PHARMACY OFFERS DRUGS AT WHOLESALE PRICES
The Whitman-Walker Clinic recently opened a pharmacy which provides services
to all persons who are HIV positive. The pharmacy can fill prescriptions
for medications used to treat HIV-related conditions. The pharmacy cannot
fill prescriptions for controlled substances such as pain medications.
The pharmacy is open on Tuesday and Thursday evenings from 6:00 - 9:00 p.m.
Your primary physician must telephone in your prescription at 483-1726
before your prescription can be filled.
The costs for medications are set at the prevailing wholesale prices.
Because of this, prices may fluctuate. Some drugs offered through the
pharmacy are available at a significantly lower price than those available
through commercial pharmacies.
Payment for medication must be in the form of cash, credit cards (VISA,
MasterCard, American Express), or personal checks in small amounts. No
third-party payments will be accepted.
In order to use the pharmacy, a person must:
1. be HIV positive;
2. have a physician call in the prescription at 483-1726;
3. be able to pay for medication in cash or by credit card or personal
check;
4. be able to pick up prescriptions during pharmacy hours.
For more information, contact the Whitman-Walker Clinic's Medical Services
department at 797-3530.
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DENTAL CLINIC AVAILABLE TO PEOPLE WITH AIDS AND ARC
The Whitman-Walker Dental Clinic provides treatment to people who are HIV
positive and who are having difficulty obtaining dental services from
outside dentists or who are unable to pay for outside dental services.
The Dental Clinic is open, by appointment only, on Mondays from 1:00 - 5:00
p.m., Wednesdays 6:00 - 8:30 p.m., and Fridays 9:00 a.m. - 12:00 p.m.
Preference is given to PWAs and emergencies. The clinic is unable to
provide crowns or denture services. There is no limit to the number of
visits.
There is no charge for services; however, donations are suggested. The
suggested donation amounts vary depending on the type of services provided.
In order to receive dental services you must be HIV positive or have an AIDS
or ARC diagnosis, and make an appointment by either coming in and speaking
with the medical receptionist or by calling 797-3533.
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HEALTHWAY OFFERS DISCOUNT
Healthway, a health and natural food store with five branches in Northern
Virginia, is offering a 25 percent discount on vitamins to people who are
HIV infected. Healthway features vitamins, natural organic foods, fresh
organic produce, dried fruit, natural cosmetics and body care products,
natural remedies, natural versions of snacks, rices, grains, frozen dinners,
vegetables, spring water, bulk foods, and many other items.
For more information, ask for the store manager (Wally at Arlington, Cheryl
at Annandale, Melinda at Fairfax, Marcy at Springfield, or Gretchen at
Manassas) or call Cheryl at 354-7782.
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SHORTCUTS
How to get a handicapped parking permit
Washington, Maryland, and Virginia all make parking permits available to
handicapped persons. There are two types of permits which allow parking in
spaces restricted to handicapped individuals. One is a permit for those
who, due to their handicap, cannot drive. This permit is for use by the
person providing transportation to the handicapped individual. The other
permit is for use by an individual who is handicapped, but can drive.
In order to obtain a permit, the handicapped person should contact the
Division of Motor Vehicles (DMV) which serves the area in which he/she
lives. That office will send the necessary application form to their home.
The form can also be obtained in person at the DMV. The application
requires identifying information on the applicant, as well as a signed
statement from his/her physician which verifies that the applicant has a
condition which warrants obtaining the permit. The completed form must be
returned to the DMV, which will issue the appropriate permit.
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AEROSOLIZED PENTAMIDINE CLINIC BEGINS
The Whitman-Walker Clinic recently announced the formation of a clinic for
the administration of aerosolized pentamidine. Note that they are not
providing the pentamidine itself (although it can be obtained through the
Clinic pharmacy), but are providing the machinery (called nebulizers) which
turns the pentamidine into a fine mist which can then be inhaled. Inhaled
pentamidine has been shown to be very effective in preventing the recurrence
of pneumocystis pneumonia.
Nebulizers are fairly expensive (several hundred dollars each), so this
clinic provides a low-cost or no-cost basis for people to receive
prophalaxis (preventative measures) against pneumocystis cariini pneumonia.
However, as the clinic is only able to provide services to a total of 48
patients, participation in the clinic is limited to individuals who have
already had one episode of pneumocystis pneumonia or who have T4 counts
below 200.
The clinic is open, by appointment only, on Tuesdays and Thursdays from 9:00
a.m. - 12:00 noon. There is no charge for treatment; however, a donation of
$10 per visit is suggested.
In order to receive pentamidine treatment at the clinic you must:
1. have had one episode of pneumocystis pneumonia or have a T4 count below
200;
2. have a written referral from your physician addressed to the Whitman-
Walker Clinic, requesting pentamidine treatment;
3. provide your own pentamidine (the clinic will aerosolize it and provide
administration);
4. contact the clinic to schedule an appointment for treatment by calling
797-3533.
If you have any questions, you can contact Dr. Basil Vareldzis at 797-3534.
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LIFELINK WILL BENEFIT FROM ROMANOVSKY & PHILLIPS CONCERT
The George Washington University Lesbian and Gay People's Alliance and
Program Board are presenting Romanovsky & Phillips in concert on Sunday,
March 19th, at the Dorothy Betts Marvin Theatre at G.W., located at 800 21st
Street, N.W., Washington, D.C. Romanovsky & Phillips have been described as
a "gay Smothers Brothers," with music ranging from folk to comedy to
ballads. Their unique style encompasses everything from do-wop to reggae.
Proceeds from the concert will benefit LifeLink, the D.C. Coalition of
People with AIDS. Ticket prices are $7.00 in advance and $11.00 at the door
for G.W. students, and $10.00 in advance and $14.00 at the door for everyone
else. Tickets are available at Lambda Rising, both branches of Lammas, the
G.W. Marvin Center, and the House of Musical Traditions in Takoma Park. For
more information or reservations, call 994-7590.
***************************************************************************
Copyright (C) 1988,1989 by Washington HIV News, all rights reserved.
Permission is granted for non-commercial use only.
--
J. Philip Miller, Professor, Division of Biostatistics, Box 8067
Washington University Medical School, St. Louis MO 63110
phil@wubios.WUstl.edu - Internet (314) 362-3617 phil@wubios.wustl - bitnet
uunet!wucs1!wubios!phil - UUCP C90562JM@WUVMD - alternate bitnet