Ten years of AIDS: The
GP's perspective
Philip Berger, MD
B ewildered. That is how I felt in the fall of 1981, shortly after the first reports of Kaposi's sarcoma (KS) and Pneumocystis carinii pneumonia (PCP) in immunocompromised gay men had been published by the Centers for Disease Control in Atlanta in its Morbidity and Mortality Weekly Reports. The community clinic where I then worked served many gay men who arrived regularly for routine venereal disease testing. A curable sexually transmitted disease (STD) was one matter, but a mysterious fatal illness that attacked the same group of men was a matter beyond my comprehension. In those early days of the AIDS epidemic, my imagination took hold. There were no textbooks to read, no major review articles to study, no experts to consult. With AIDS, diagnosis and treatment were no longer straightforward parts of practice. Doctors were helpless. Although Canada's first case of AIDS would not be reported until February 1982, in the fall of 1981 I began searching for peculiar, purplish skin lesions in all my gay patients. I really did not know what I was looking for, because I had never before seen KS. Soon enough I detected a solitary nodule on the leg of a healthy, unsuspecting patient, and made an urgent referral to Dr. Colin Ramsay, a Toronto dermatologist. Philip Berger, a family physician, practises in Toronto. He is cochairman of the Toronto HIV Primary Care Physicians Group. 378
CAN MED ASSOCJ 1992; 146 (3)
I still remember his blunt admission of confusion in the face of this new illness. A biopsy confirmed the diagnosis of dermatofibroma - not KS - but nevertheless, that patient is now living with confirmed HIV infection. Colin Ramsay remains as humble and kind as ever in his treatment of many HIV-infected patients. HIV does humble physicians. And kindness should be paramount in our efforts to temper the devastation of this infeetion.
April 1985 after I had attended the 1st International Conference on AIDS in Atlanta. The horror and extent of the AIDS epidemic was chilling. No treatment was in sight. The potential for HIV transmission was the topic of many coffee-table and bar-room conversations. I left Atlanta with an urgent need to pass on the conference message of prevention. Within days of arriving home I submitted an op-ed piece to the Globe and -.i
y the end of 199 11 had been the primary care physician for about 300 HIV-infected patients; 70 are now dead. Five of them committed suicide. Another died of a heroin overdose and his body remained undiscovered for a full week.
It has been a long, painful decade since I made that first panicky referral. By the end of 1991 I had been the primary care physician for about 300 HIVinfected patients; 70 are now dead. Five of them committed suicide. Another died of a heroin overdose and his body remained undiscovered for a full week. His landlord finally called the police when the stench from his apartment became overbearing. Shock. That is what I felt in
Mail. Its subject was the compel-
ling need for STD and sex education in our schools, but the article was rejected. The editor felt it contributed little to the discussion about sex education. (The newspaper has since become a leader in reporting and analysing the AIDS epidemic.) The Atlanta conference was my first encounter with the politics of AIDS. "No test is best" buttons were being distributed by American AIDS activists, who also challenged scientists and poliLE lt11F£VRIER 1992
Pregnancy/Nursing Mothers
ticians during the plenary sessions. "Politics," my colleague Dr. Alex Klein would exclaim a few years later. "It's amazing, the politics." The 5th International Conference on AIDS was held in Montreal in June 1989 and offered an unprecedented mixture of politics and science. American and Canadian AIDS activists took over the stage just prior to the conference opening. I will never forget seeing my patient Tim McCaskell proclaim the conference "officially open" before an audience of thousands; Prime Minister Brian Mulroney was standing in the wings as he made that announcement. I felt a certain pride as I watched Tim stand there, steadfast in his determination that the demands of HIV-infected persons be heeded. AIDS activism has permanently changed every sector connected with the AIDS epidemic. Tim McCaskell was an invited speaker at a fall 1991 meeting of the Canadian HIV Trials Network. He and other patients who have HIV disease have been appointed to the Ontario Advisory Committee on HIV/AIDS. Patients have also been appointed to ethics review committees connected with clinical trials. This happened 3 years after a demonstration in London, Ont., during a national meeting of clinical trial investigators. Health care and research are becoming "patient driven," the activists stress. But a patient-driven system can be hard on the day-to-day practice of medicine. As a physician who has long argued for an equal relationship between patient and doctor, AIDS has put my principles to a rigorous test. Patients routinely arrive with requests for laboratory tests of dubious value - they may want to have their vitamin levels measured. Some patients disregard official recommendations for initiation of antiviral treatment FEBRUARY 1, 1992
(Particle coated erthromycin tablets) BRIEF PRESCRIBING INFORMATION Antibiotic Therapeutic- Classification: Indications and Clinical Uses Erythromycin is indicated for the treatment of infections caused by susceptible strains of microorganisms in the following diseases: Upper and lower respiratory tract infections, skin and soft tissue infections, primary syphilis, diphtheria, erythrasma, pertussis, legionnaires' disease, chlamydial infections, acne vulgaris, prophylaxis of bacterial endocarditis.
Contraindications Erythromycin is contraindicated in patients with known hypersensitivity to this antibiotic.
Warnings Erythromycin should be administered with caution to any patient who has demonstrated some form of allergy to drugs. If an allergic reaction to erythromycin occurs, administration of the drug should be discontinued. Serious hypersensitivity reactions may require epinephrine, antihistamines, or corticosteroids. There have been reports of hepatic dysfunction, with or without jaundice, occurring in patients receiving erythromycin products. If findings suggestive of significant hepatic dysfunction occur, therapy with erythromycin products should be discontinued. Pseudomembranous colitis has been occasionally reported to occur in association with erythromycin therapy. Therefore, it is important to consider its diagnosis in patients administered erythromycin who develop diarrhea. Mild cases of colitis may respond to drug discontinuation alone. Moderate to severe cases should be managed with fluid, electrolyte and protein supplementation as indicated. If the colitis is not relieved by discontinuation of erythromycin administration or when it is severe, consideration should be given to the administration of vancomycin or other suitable therapy. Other possible causes of the colitis should also be considered.
Precautions Prolonged or repeated use of erythromycin may result in an overgrowth of non-susceptible bacteria orfungi and organisms initially sensitive to erythromycin (e.g. Staphylococcus aureus, Hemophilus influenzae). If superinfection occurs, erythromycin should be discontinued and appropriate therapy instituted. Since erythromycin is principally excreted by the liver, caution should be exercised when erythromycin is administered to patients with impaired hepatic function.
Drug Interactions Theophylline The concomitant administration of erythromycin and high doses of theophylline may be associated with an increase in serum theophylline levels and potential theophylline toxicity. In case of theophylline toxicity and/or elevated serum theophylline levels, the dose of theophylline should be reduced while the patient is receiving concomitant erythromycin therapy. There have been published reports suggesting that when oral erythromycin is given concurrently with theophylline, there is a significant decrease in erythromycin serum concentrations. This decrease could result in subtherapeutic concentrations of erythromycin. Erythromycin should also be used with caution if administered concomitantly with the following drugs: lincomycin, clindamycin, chloramphenicol, carbamazepine, digoxin, phenytoin, oral anticoagulants, triazolam, cyclosporin, ergotamine, alfentanil, hexobarbital.
The safety of erythromycin for use during pregnancy and breast feeding has not been established. Erythromycin crosses the placental barrier and is excreted in breast milk.
Adverse Reactions Gastrointestinal: Abdominal cramping, discomfort, nausea, vomiting, diarrhea, and anorexia. Pancreatitis Allergic reactions: Urticaria, mild skin eruptions and anaphylaxis. Cardiovascular: Occasional case reports of cardiac arrhythmias such as ventricular tachycardia have been documented in patients receiving erythromycin therapy. Neurological: Central nervous system side effects including seizures, hallucinations, confusion and vertigo have been reported in occasional patients; however, a cause and effect relationship has not been established.
Hepatotoxicity Miscellaneous: Occasionally there have been reports of reversible hearing loss occurring chiefly in patients with renal insufficiency and in patients receiving high doses of erythromycin.
Dosage and Administration Treatment Usual adult dosage: ERYBiD* 500-mg tablets should be administered every 12 hours. Maximum blood levels are obtained when ERYBiD* is given in the fasting state (1/2 hour and preferably 2 hours before meals). For group A streptococcal infections, therapy should be continued for at least 10 days. For severe infections: Up to 4 g of erythromycin may be given daily in divided doses. For acne vulgaris: Initially, up to one gram per day in divided doses. Depending on clinical response this may then be reduced to 333 to 500 mg per day as maintenance dose. Extended administration of erythromycin requires regular evaluation, particularly of liver function. Chlamydial infections: a) Pregnant women and nursing mothers: 500 mg orally q.i.d. for 7 days or 250 mg orally q.i.d. for 14 days if the larger dose is not tolerated; b) Adolescents and adults when tetracycline or doxycycline is contraindicated or not tolerated: 500 mg q.i.d. for 7 days; c) Complicated infection: the duration of treatment should be for at least 10 days. Prophylaxis: For prophylaxis against bacterial endocarditis due to alpha-hemolytic streptococci in penicillin-allergic patients with valvular heart disease when undergoing dental procedures or surgical procedures of the upper respiratorytract, the adult dose is 1 g orally 1 hour prior to the procedure, and then 500 mg orally 6 hours later. For continuous prophylaxis against recurrences of streptococcal infections in persons with a history of rheumatic heart disease, the dose is 250 mg twice a day.
Availability ERYBiD* (Particle coated erythromycin tablets) is supplied in bottles of 100 and 250 white Dispertab* tablets containing 500 mg of erythromycin base. Full prescribing information available upon request.
References 1. Study M89-295, data on file, Abbott Laboratories. 2. Study F89-160, data on file, Abbott Laboratories. 3. Study F89-161, data on file, Abbott Laboratories. ORALCANOOUCTA
D
AUOTT LOflTOUEU. LIWUED
|_
O
MONTRcAL. CANADA
Member *
CAN MED ASSOC J 1992; 146 (3)
TM
379
In 1992, I have a new-found respect for certain members of our profession. For the surgeons who, without complaint, operate on AIDS patients. For the subspecialist internists on standby for urgent investigations and treatments. And
for that small cadre of anonymous general practitioners who spend their days putting out the HIV-related brushfires that constantly erupt. sometimes with just cause. Others aminations. It never occurred to the struggle against AIDS, leaving purchase experimental drugs me until after his death that had I behind years of bitterness and through American buyers' clubs stopped listening to his chest I confrontation. Individual governthat will sell just about any "treat- would also have stopped touching ment bureaucrats have become ment" available. his ravaged body. To the patient flexible and committed to the sucI remember the Wednesday this would have represented a re- cess of their programs - the loosseveral years ago when a patient jection. It was the touching, not ening of the rules governing the arrived clutching that day's edi- the auscultation, that signalled my federal Emergency Drug Release tion of the New York Times. continuing acceptance and re- Program is one example. Persons There was a front-page story on spect. with HIV are now living longer I don't normally communi- and better lives. the benefits of taking wafer biscuits soaked in interferon. I had cate with patients by using physiFinally, AIDS has taught me never heard of the oral adminis- cal contact. Since that young man that the medical profession can tration of interferon and certainly died, I have deliberately touched never become complacent, no had no knowledge of its delivery the sometimes hideous lesions in matter how advanced its technolovia wafer biscuits. other patients plagued by this gy or how effective its arsenal of Patients' participation in pol- feared consequence of AIDS. treatments. AIDS has made toHope. The 3rd International day's doctors hark back to the icy and treatment decisions has arisen because of their need to Conference on AIDS held in time when comfort and solace maintain control over their lives Washington, DC, in June 1987 were all physicians could offer the in the face of an eventually uncon- offered the first hope for patients sick and dying. trollable infection. Despite medi- infected with HIV. It was called a In 1992, I have a new-found cine's failure to halt the inexora- watershed meeting because of the respect for certain members of our ble march to death, physicians can prospective therapies that had profession. For the surgeons who, ease the grief along the way. been developed. I remember the without complaint, operate on A few years ago a young man optimism and excitement that AIDS patients. For the subspecialin my practice developed KS. permeated the conference. ist internists on standby for urgent Within a few months of noticing Today, three antiretroviral investigations and treatments. his first lesion he was covered drugs - zidovudine (AZT), di- And for that small cadre of anonywith plum-sized, purplish nodules, deoxyinosine (ddl) and dideox- mous general practitioners who many of which were ulcerating. ycytidine (ddC) - are available. spend their days putting out the No part of his body was spared. Prophylaxis for PCP and preven- brushfires that constantly erupt His face was puffy, his nose de- tive treatment for tuberculosis are during the course of HIV infecformed and his legs grossly ede- now routine. Treatment of oppor- tion. matous from the onslaught of KS. tunistic infections is improving Bewilderment, shock and He was unresponsive to all treat- with earlier detection and a wider hope is my experience with AIDS. ment. He continued to arrive for choice of pharmacologic agents. The anticipation of further breakbiweekly examinations. Combination therapy against HIV throughs in the management of Part of his usual monitoring and prophylaxis against multiple HIV makes contending with the included my listening to his chest, infections seem to be the way of daily tragedies more bearable. as I had always done. While ex- the future. In my heart I believe that There are other reasons for science will triumph, placing HIV amining him I would privately contemplate the futility of what hope. Patients, physicians and sci- in that category of epidemics we had become ritualistic physical ex- entists have forged an alliance in have endured and conquered.o 380
CAN MED ASSOC J 1992; 146 (3)
LE 1- F£VRIER 1992
GP's perspective
Philip Berger, MD
B ewildered. That is how I felt in the fall of 1981, shortly after the first reports of Kaposi's sarcoma (KS) and Pneumocystis carinii pneumonia (PCP) in immunocompromised gay men had been published by the Centers for Disease Control in Atlanta in its Morbidity and Mortality Weekly Reports. The community clinic where I then worked served many gay men who arrived regularly for routine venereal disease testing. A curable sexually transmitted disease (STD) was one matter, but a mysterious fatal illness that attacked the same group of men was a matter beyond my comprehension. In those early days of the AIDS epidemic, my imagination took hold. There were no textbooks to read, no major review articles to study, no experts to consult. With AIDS, diagnosis and treatment were no longer straightforward parts of practice. Doctors were helpless. Although Canada's first case of AIDS would not be reported until February 1982, in the fall of 1981 I began searching for peculiar, purplish skin lesions in all my gay patients. I really did not know what I was looking for, because I had never before seen KS. Soon enough I detected a solitary nodule on the leg of a healthy, unsuspecting patient, and made an urgent referral to Dr. Colin Ramsay, a Toronto dermatologist. Philip Berger, a family physician, practises in Toronto. He is cochairman of the Toronto HIV Primary Care Physicians Group. 378
CAN MED ASSOCJ 1992; 146 (3)
I still remember his blunt admission of confusion in the face of this new illness. A biopsy confirmed the diagnosis of dermatofibroma - not KS - but nevertheless, that patient is now living with confirmed HIV infection. Colin Ramsay remains as humble and kind as ever in his treatment of many HIV-infected patients. HIV does humble physicians. And kindness should be paramount in our efforts to temper the devastation of this infeetion.
April 1985 after I had attended the 1st International Conference on AIDS in Atlanta. The horror and extent of the AIDS epidemic was chilling. No treatment was in sight. The potential for HIV transmission was the topic of many coffee-table and bar-room conversations. I left Atlanta with an urgent need to pass on the conference message of prevention. Within days of arriving home I submitted an op-ed piece to the Globe and -.i
y the end of 199 11 had been the primary care physician for about 300 HIV-infected patients; 70 are now dead. Five of them committed suicide. Another died of a heroin overdose and his body remained undiscovered for a full week.
It has been a long, painful decade since I made that first panicky referral. By the end of 1991 I had been the primary care physician for about 300 HIVinfected patients; 70 are now dead. Five of them committed suicide. Another died of a heroin overdose and his body remained undiscovered for a full week. His landlord finally called the police when the stench from his apartment became overbearing. Shock. That is what I felt in
Mail. Its subject was the compel-
ling need for STD and sex education in our schools, but the article was rejected. The editor felt it contributed little to the discussion about sex education. (The newspaper has since become a leader in reporting and analysing the AIDS epidemic.) The Atlanta conference was my first encounter with the politics of AIDS. "No test is best" buttons were being distributed by American AIDS activists, who also challenged scientists and poliLE lt11F£VRIER 1992
Pregnancy/Nursing Mothers
ticians during the plenary sessions. "Politics," my colleague Dr. Alex Klein would exclaim a few years later. "It's amazing, the politics." The 5th International Conference on AIDS was held in Montreal in June 1989 and offered an unprecedented mixture of politics and science. American and Canadian AIDS activists took over the stage just prior to the conference opening. I will never forget seeing my patient Tim McCaskell proclaim the conference "officially open" before an audience of thousands; Prime Minister Brian Mulroney was standing in the wings as he made that announcement. I felt a certain pride as I watched Tim stand there, steadfast in his determination that the demands of HIV-infected persons be heeded. AIDS activism has permanently changed every sector connected with the AIDS epidemic. Tim McCaskell was an invited speaker at a fall 1991 meeting of the Canadian HIV Trials Network. He and other patients who have HIV disease have been appointed to the Ontario Advisory Committee on HIV/AIDS. Patients have also been appointed to ethics review committees connected with clinical trials. This happened 3 years after a demonstration in London, Ont., during a national meeting of clinical trial investigators. Health care and research are becoming "patient driven," the activists stress. But a patient-driven system can be hard on the day-to-day practice of medicine. As a physician who has long argued for an equal relationship between patient and doctor, AIDS has put my principles to a rigorous test. Patients routinely arrive with requests for laboratory tests of dubious value - they may want to have their vitamin levels measured. Some patients disregard official recommendations for initiation of antiviral treatment FEBRUARY 1, 1992
(Particle coated erthromycin tablets) BRIEF PRESCRIBING INFORMATION Antibiotic Therapeutic- Classification: Indications and Clinical Uses Erythromycin is indicated for the treatment of infections caused by susceptible strains of microorganisms in the following diseases: Upper and lower respiratory tract infections, skin and soft tissue infections, primary syphilis, diphtheria, erythrasma, pertussis, legionnaires' disease, chlamydial infections, acne vulgaris, prophylaxis of bacterial endocarditis.
Contraindications Erythromycin is contraindicated in patients with known hypersensitivity to this antibiotic.
Warnings Erythromycin should be administered with caution to any patient who has demonstrated some form of allergy to drugs. If an allergic reaction to erythromycin occurs, administration of the drug should be discontinued. Serious hypersensitivity reactions may require epinephrine, antihistamines, or corticosteroids. There have been reports of hepatic dysfunction, with or without jaundice, occurring in patients receiving erythromycin products. If findings suggestive of significant hepatic dysfunction occur, therapy with erythromycin products should be discontinued. Pseudomembranous colitis has been occasionally reported to occur in association with erythromycin therapy. Therefore, it is important to consider its diagnosis in patients administered erythromycin who develop diarrhea. Mild cases of colitis may respond to drug discontinuation alone. Moderate to severe cases should be managed with fluid, electrolyte and protein supplementation as indicated. If the colitis is not relieved by discontinuation of erythromycin administration or when it is severe, consideration should be given to the administration of vancomycin or other suitable therapy. Other possible causes of the colitis should also be considered.
Precautions Prolonged or repeated use of erythromycin may result in an overgrowth of non-susceptible bacteria orfungi and organisms initially sensitive to erythromycin (e.g. Staphylococcus aureus, Hemophilus influenzae). If superinfection occurs, erythromycin should be discontinued and appropriate therapy instituted. Since erythromycin is principally excreted by the liver, caution should be exercised when erythromycin is administered to patients with impaired hepatic function.
Drug Interactions Theophylline The concomitant administration of erythromycin and high doses of theophylline may be associated with an increase in serum theophylline levels and potential theophylline toxicity. In case of theophylline toxicity and/or elevated serum theophylline levels, the dose of theophylline should be reduced while the patient is receiving concomitant erythromycin therapy. There have been published reports suggesting that when oral erythromycin is given concurrently with theophylline, there is a significant decrease in erythromycin serum concentrations. This decrease could result in subtherapeutic concentrations of erythromycin. Erythromycin should also be used with caution if administered concomitantly with the following drugs: lincomycin, clindamycin, chloramphenicol, carbamazepine, digoxin, phenytoin, oral anticoagulants, triazolam, cyclosporin, ergotamine, alfentanil, hexobarbital.
The safety of erythromycin for use during pregnancy and breast feeding has not been established. Erythromycin crosses the placental barrier and is excreted in breast milk.
Adverse Reactions Gastrointestinal: Abdominal cramping, discomfort, nausea, vomiting, diarrhea, and anorexia. Pancreatitis Allergic reactions: Urticaria, mild skin eruptions and anaphylaxis. Cardiovascular: Occasional case reports of cardiac arrhythmias such as ventricular tachycardia have been documented in patients receiving erythromycin therapy. Neurological: Central nervous system side effects including seizures, hallucinations, confusion and vertigo have been reported in occasional patients; however, a cause and effect relationship has not been established.
Hepatotoxicity Miscellaneous: Occasionally there have been reports of reversible hearing loss occurring chiefly in patients with renal insufficiency and in patients receiving high doses of erythromycin.
Dosage and Administration Treatment Usual adult dosage: ERYBiD* 500-mg tablets should be administered every 12 hours. Maximum blood levels are obtained when ERYBiD* is given in the fasting state (1/2 hour and preferably 2 hours before meals). For group A streptococcal infections, therapy should be continued for at least 10 days. For severe infections: Up to 4 g of erythromycin may be given daily in divided doses. For acne vulgaris: Initially, up to one gram per day in divided doses. Depending on clinical response this may then be reduced to 333 to 500 mg per day as maintenance dose. Extended administration of erythromycin requires regular evaluation, particularly of liver function. Chlamydial infections: a) Pregnant women and nursing mothers: 500 mg orally q.i.d. for 7 days or 250 mg orally q.i.d. for 14 days if the larger dose is not tolerated; b) Adolescents and adults when tetracycline or doxycycline is contraindicated or not tolerated: 500 mg q.i.d. for 7 days; c) Complicated infection: the duration of treatment should be for at least 10 days. Prophylaxis: For prophylaxis against bacterial endocarditis due to alpha-hemolytic streptococci in penicillin-allergic patients with valvular heart disease when undergoing dental procedures or surgical procedures of the upper respiratorytract, the adult dose is 1 g orally 1 hour prior to the procedure, and then 500 mg orally 6 hours later. For continuous prophylaxis against recurrences of streptococcal infections in persons with a history of rheumatic heart disease, the dose is 250 mg twice a day.
Availability ERYBiD* (Particle coated erythromycin tablets) is supplied in bottles of 100 and 250 white Dispertab* tablets containing 500 mg of erythromycin base. Full prescribing information available upon request.
References 1. Study M89-295, data on file, Abbott Laboratories. 2. Study F89-160, data on file, Abbott Laboratories. 3. Study F89-161, data on file, Abbott Laboratories. ORALCANOOUCTA
D
AUOTT LOflTOUEU. LIWUED
|_
O
MONTRcAL. CANADA
Member *
CAN MED ASSOC J 1992; 146 (3)
TM
379
In 1992, I have a new-found respect for certain members of our profession. For the surgeons who, without complaint, operate on AIDS patients. For the subspecialist internists on standby for urgent investigations and treatments. And
for that small cadre of anonymous general practitioners who spend their days putting out the HIV-related brushfires that constantly erupt. sometimes with just cause. Others aminations. It never occurred to the struggle against AIDS, leaving purchase experimental drugs me until after his death that had I behind years of bitterness and through American buyers' clubs stopped listening to his chest I confrontation. Individual governthat will sell just about any "treat- would also have stopped touching ment bureaucrats have become ment" available. his ravaged body. To the patient flexible and committed to the sucI remember the Wednesday this would have represented a re- cess of their programs - the loosseveral years ago when a patient jection. It was the touching, not ening of the rules governing the arrived clutching that day's edi- the auscultation, that signalled my federal Emergency Drug Release tion of the New York Times. continuing acceptance and re- Program is one example. Persons There was a front-page story on spect. with HIV are now living longer I don't normally communi- and better lives. the benefits of taking wafer biscuits soaked in interferon. I had cate with patients by using physiFinally, AIDS has taught me never heard of the oral adminis- cal contact. Since that young man that the medical profession can tration of interferon and certainly died, I have deliberately touched never become complacent, no had no knowledge of its delivery the sometimes hideous lesions in matter how advanced its technolovia wafer biscuits. other patients plagued by this gy or how effective its arsenal of Patients' participation in pol- feared consequence of AIDS. treatments. AIDS has made toHope. The 3rd International day's doctors hark back to the icy and treatment decisions has arisen because of their need to Conference on AIDS held in time when comfort and solace maintain control over their lives Washington, DC, in June 1987 were all physicians could offer the in the face of an eventually uncon- offered the first hope for patients sick and dying. trollable infection. Despite medi- infected with HIV. It was called a In 1992, I have a new-found cine's failure to halt the inexora- watershed meeting because of the respect for certain members of our ble march to death, physicians can prospective therapies that had profession. For the surgeons who, ease the grief along the way. been developed. I remember the without complaint, operate on A few years ago a young man optimism and excitement that AIDS patients. For the subspecialin my practice developed KS. permeated the conference. ist internists on standby for urgent Within a few months of noticing Today, three antiretroviral investigations and treatments. his first lesion he was covered drugs - zidovudine (AZT), di- And for that small cadre of anonywith plum-sized, purplish nodules, deoxyinosine (ddl) and dideox- mous general practitioners who many of which were ulcerating. ycytidine (ddC) - are available. spend their days putting out the No part of his body was spared. Prophylaxis for PCP and preven- brushfires that constantly erupt His face was puffy, his nose de- tive treatment for tuberculosis are during the course of HIV infecformed and his legs grossly ede- now routine. Treatment of oppor- tion. matous from the onslaught of KS. tunistic infections is improving Bewilderment, shock and He was unresponsive to all treat- with earlier detection and a wider hope is my experience with AIDS. ment. He continued to arrive for choice of pharmacologic agents. The anticipation of further breakbiweekly examinations. Combination therapy against HIV throughs in the management of Part of his usual monitoring and prophylaxis against multiple HIV makes contending with the included my listening to his chest, infections seem to be the way of daily tragedies more bearable. as I had always done. While ex- the future. In my heart I believe that There are other reasons for science will triumph, placing HIV amining him I would privately contemplate the futility of what hope. Patients, physicians and sci- in that category of epidemics we had become ritualistic physical ex- entists have forged an alliance in have endured and conquered.o 380
CAN MED ASSOC J 1992; 146 (3)
LE 1- F£VRIER 1992
