Medical treatment and advice for an adult male who knows he carries the Human Immunodeficiency Virus (HIV) is a challenge. But what about treatment for a pregnant mother who doesn't even know she's HIV-positive?
Since health professionals at the Health Science Center and elsewhere began dealing with cases of Acquired Immune Deficiency Syndrome (AIDS) around 1980, their focus of attention has had to change and expand.
Although the number of HIV-positive individuals is growing and demographics are changing, drug trials and other experimental procedures to improve treatment are under way and caregivers are offering some hope to patients.
Initial treatments and prevention efforts targeted the adult males who were the primary AIDS sufferers. Adult males were quickly joined by adult females and their children, necessitating much broader and more specialized treatment and prevention efforts.
Today, Health Science Center faculty and staff dealing with HIV range from infectious disease specialists to dentists, pediatricians, nurses, hematologists, oncologists, psychologists and psychiatrists.
Terence Doran, MD, PhD, assistant professor of pediatrics/infectious diseases, directs the South Texas AIDS Center for Children (STAC) and Their Families.
"We care for HIV-positive children and their families in 47 counties of South Texas, including Bexar County," Dr. Doran said. "Some mothers don't know they're carrying the virus when they give birth. In many cases, the symptomatic child is the first indicator to the family and the physician that HIV is present in the family."
The STAC is considered a national model program for treatment of HIV-positive children and young adults. Former U.S. Surgeon General Dr. Antonia Novello visited the program's headquarters here in 1992 and President Clinton's national AIDS policy coordinator Kristine Gebbie visited the program last fall and interviewed several adolescents who are HIV-positive.
The program offers holistic family care, including the services of physicians, psychologists, nutritionists and nurses. This approach dovetails with the findings by a panel of experts published in the Dec. 1, 1993, Journal of the American Medical Association. The article noted that "management of overall health status, counseling to reduce risk behaviors, provision of psychosocial support, assessment of quality-of-life issues and prevention of opportunistic infections all are in the domain of the clinician- patient relationship. The HIV epidemic reminds practitioners that the finest expression of medicine lies in the optimal blend of science and the art of patient care."
Optimum management of HIV-positive children requires identification of the at-risk infant by the time of delivery or earlier, Dr. Doran said. "This allows intervention to prevent many HIV-related complications, improves quality and length of life, and allows education of the parents to decrease spread of disease to sex partners and subsequent children.
"We are finding more and more HIV disease occurring in smaller communities. As the HIV epidemic evolves, greater impact will occur in previously unaffected populations, so that the scope of awareness, education and HIV testing will need to be expanded," he said.
"Women with classic risk factors such as multiple sex partners and injecting drug use need to be targeted for HIV testing, but women who do not fit the profile of 'high risk' for HIV will be an increasing percentage of cases," Dr. Doran said.
The STAC finds in smaller communities that mothers more often contracted HIV through sexual contact, but in larger cities such as San Antonio, intravenous drug use is still a major risk factor for spreading the HIV infection.
Faculty are developing prevention programs to stem the tide of HIV infection on the streets of San Antonio. For example, Kenneth Vogtsberger, MD, associate professor of psychiatry, directs the Screening, Treatment, Education and Prevention Services (STEPS) project funded by the federal Center for Substance Abuse Treatment. A primary goal is to facilitate drug users' enrollment into formal drug treatment programs.
"We estimate that there are about 15,000 to 20,000 injecting drug users in San Antonio," Dr. Vogtsberger said. "We are testing a large group of these people for HIV, other sexually transmitted diseases and tuberculosis and referring them for appropriate care.
"Our other target groups include crack cocaine users and the sexual partners of these high-risk drug users," he said.
The project performs pregnancy tests for drug-using women of child-bearing age and outreach workers counsel the drug users on ways to reduce their risk of contracting communicable diseases.
"We're successfully contacting and educating members of this population about HIV and other infection risks, but there's still a need for drug treatment facilities for indigent patients that is overwhelming the resources in the community," Dr. Vogtsberger said.
Dr. Doran added: "Unless HIV education, counseling and testing services are improved for women who are pregnant or contemplating pregnancy, who have had partners with known or suspected risks, or who have concerns about symptoms or exposures, we will continue to see delayed diagnosis and increased morbidity and mortality among HIV-infected women and children."
One population of HIV-positive individuals not increasing is the one made up of people who got the virus from a blood transfusion. The nation's blood supply has been screened for HIV since 1985 and most hemophiliacs and others who contracted the virus from that source were infected prior to that date.
Nevertheless, Richard Parmley, MD, professor of pediatrics and head of the department's hematology/oncology division, said that the South Texas Regional Hemophilia Center still follows about 40 patients through its HIV surveillance program.
"About 20 of them are adolescents and the others are young adults. About half of the initial 70 patients the center followed in 1985 are alive today," Dr. Parmley said.
"We have drugs that help delay the immune system's decay, but the real advances have come in supportive care," he said. "For example, we have better medications to treat secondary infections when they occur."
Infectious disease specialist Jean Smith, MD, assistant professor of medicine/infectious diseases, believes that multiple drug therapy is very helpful and finds cause for optimism in her work with HIV and AIDS.
"The outlook for patients infected with HIV has improved dramatically," Dr. Smith said. "Within three to five years, HIV infection may no longer be a death sentence, but instead a chronic disease manageable with multiple drug therapies.
"We are moving toward combination therapies that hit the virus in various different targets," she said. "And a number of opportunistic infections associated with AIDS now can be prevented with therapy, or managed before they become severe.
"Within the next five to six years, we will probably be treating HIV infection much like we do hypertension," she said. "It will be a chronic problem, but in the majority of people, it will be managed."
According to Dr. Smith, the drug zidovudine (AZT) is still recommended as the first-line therapy for immunocompromised patients. However, specialists, including Dr. Smith and others now are conducting trials to learn whether AZT should be alternated or combined with drugs such as dideoxyinosine (ddI), dideoxycytidine (ddC) or another drug that works in a different way from the other three.
"What's becoming clear," Dr. Smith said, "is that over time, people develop resistance to AZT. Some studies are examining whether it's better to give people AZT for a year or two, then switch to ddI for a year or two, and maybe go back to AZT."
Patricia Sharkey-Mathis, MD, assistant professor of medicine in the division of infectious diseases, reports that the infectious diseases division currently has more than 15 drug studies under way testing protocols for AIDS treatment. Dr. Sharkey-Mathis is medical director of the Family Focused AIDS/HIV Clinical Treatment and Services (FFACTS) Clinic located at the University Health Center- Downtown (formerly the Brady/Green Community Health Center). She also chairs the Bexar County AIDS Consortium and the Texas Department of Health HIV Services Advisory Committee. "We try to keep costs down by coordinating AIDS activities locally and statewide," she said.
In response to the changing demographics of the patient population, the FFACTS clinic has recently added a once-a-week women's clinic supervised by Ernesto Parra, MD, assistant professor of family practice.
Another treatment site staffed, in part, by Health Science Center faculty is the San Antonio AIDS Foundation. Dental care is a major activity at the foundation in addition to medical care.
"At the AIDS Foundation, dentists from the Health Science Center are helping treat more than 80 HIV-positive patients per month at the Ryan White Dental Clinic," said John Prows, DDS, director of the federally-funded dental clinic and instructor in dental diagnostic science.
According to Dr. Prows, the clinic is seeing about 15 new patients per month. "The Ryan White clinic is the only dental facility in San Antonio solely dedicated to providing dental care for the HIV/AIDS population in Bexar as well as 11 other counties," he said.
Dr. Prows is concerned because the center's federal budget was reduced by a third last year, making delivery of care a challenge, despite donated care and equipment.
Health Science Center faculty also see HIV-positive dental patients at other sites including the Special Patient Care clinic at University Hospital (formerly Medical Center Hospital), and at the University Health Center-Downtown.
With the help of a Texas Department of Health grant, Dr. Prows and Chih-Ko Yeh, assistant professor of dental diagnostic science, have prepared a training film for patients about dental hygiene techniques and how to watch for oral lesions associated with the HIV infection.
Alison Berry, MD, assistant professor of medicine/infectious diseases, sees HIV-positive patients in her role as medical director of the San Antonio AIDS Foundation and director of the immunosuppression clinic at Audie L. Murphy Memorial Veterans Hospital.
"Numbers of AIDS patients at the VA in San Antonio have doubled over the past year, but the good news is, they're living longer," Dr. Berry said. She attributes the longer survival to earlier diagnosis and preventive therapies.
Although numbers of patients infected with HIV are increasing and the health care system is straining to try to keep up with the situation, clinicians and patients are holding a hopeful thought. With ongoing drug trials, education and prevention efforts, and immune system research, they seem able to agree with Drs. Sharkey- Mathis and Smith that HIV infection is gradually becoming more like diabetes. Although it's not yet curable, it's becoming treatable.