AIDS Treatment and Research

December 1998

VA is the nation's largest single source of HIV (Human Immunodeficiency Virus) care. It has provided treatment to more than 45,000 individuals with HIV infection and Acquired Immune Deficiency Syndrome (AIDS) since AIDS was first recognized in the United States in 1981. VA physicians were among the first to report the new syndrome. Reporting in VA began in 1983 when 61 patients were treated in VA's health-care system. Today, between 16,000 and 17,000 patients with HIV or AIDS are treated at VA facilities.

Clinical guidance on the appropriate use of new therapies has been developed by a group of leading international clinical and research experts including VA AIDS experts from across the country. VA's guidelines include recommendations on promising new drugs against HIV, including protease inhibitors and the use of combination anti-retroviral treatment and viral load measurements. These efforts also have encompassed recommendations for preventing and treating opportunistic infections in HIV and AIDS patients, conditions which can flourish when the immune system is suppressed by the underlying disease. In the past, the approach of American medicine generally was to initiate AIDS treatment when HIV-positive patients exhibited signs of extreme illness, but the goal of treatment today begins with bringing the virus to undetectable levels. Recently, newer pharmaceutical combinations have been prolonging life in persons with HIV or AIDS, at least in the short term. VA's guidelines require that all licensed anti-retroviral drugs be made available at each facility, offer guidance for choosing the best combinations, and provide recommendations to minimize and deal with drug resistance. These steps reflect VA's commitment to technology transfer, taking knowledge gained from its world-class research program in such areas as viral load monitoring and applying it to clinical care.

VA's AIDS program is a comprehensive approach with increased emphasis on outpatient services, active case management, and tracking of HIV-positive veterans through a registry that provides clinical, administrative and management reports.

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TRAINING

VA conducts national training programs and teleconferences on timely issues related to prevention and treatment of HIV/AIDS and patient health education. Teleconferences were recently held on occupational exposure to blood-borne pathogens and opportunistic infections. In addition, teleconferences were held for all HIV care providers to update them on clinical care of HIV/AIDS patients. VA routinely trains new and replacement counselors at VA medical centers who have primary responsibility for educating patients in preventive measures and for providing pre- and post-HIV antibody test counseling.

SPECIAL CARE MODELS

In addition to the medical and health-care services available at all facilities, VA has four dedicated AIDS clinical units designed to serve as models for innovative delivery of health-care services and medical treatment throughout the system. These clinical units are located at medical centers with large numbers of veterans with HIV infection or AIDS -- New York, Miami, Los Angeles and San Francisco. The models of care vary from dedicated inpatient units to an outpatient model which integrates inpatient services on general medical units. Each model uses a multidisciplinary team approach for coordinated and comprehensive inpatient and outpatient care.

A VA national survey of VA HIV/AIDS programs found a broad array of medical, preventive, education, counseling, case management and support services. Medical care is furnished in a variety of inpatient and outpatient settings, including hospitals, nursing homes, hospices, and in the veteran's home. Treatment regimens embody the latest technological advances, the Under Secretary's National Survey of VA HIV/AIDS Treatment and Prevention Programs found.

RESEARCH

VA conducts wide-ranging research in AIDS, from basic studies of the mechanisms of AIDS to clinical trials and assessments of the costs of patient care. Special research initiatives are a critical part of VA's response to AIDS. Now in their 10th year of funding, four special centers for AIDS research-Atlanta; Durham, N.C.; New York; and San Diego-are part of VA's efforts to improve the diagnosis, treatment, and prevention of the disease.

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Research at the four centers includes studies of the bacterial and mycobacterial complications of HIV infection, the epidemiology and clinical effects of resistance to anti-retroviral drugs, and markers of clinical progression of the disease.

Scientists at the special centers and at other VA medical centers across the country last year received nearly $32.6 million in funding from VA and other sources to support more than 322 separate HIV research projects. Recent research advances by VA investigators include:

• In findings that may help guide physicians treating HIV-infected patients, Los Angeles researchers and their colleagues found that blood levels of virus, in addition to counts of the CD4 cells targeted by HIV, could reliably predict success of drug therapy.
  
• Bronx (NY) investigators found that the drug thalidomide promoted complete healing in many patients suffering from the debilitating "aphthous" ulcers of the mouth and throat that can complicate advanced HIV infection.
  
• Among leaders in efforts to develop a vaccine against the AIDS virus, New York researchers recently reported a vaccine regimen that induced promising antibody production in animals.
  
• A study on national trends in inpatient and outpatient care utilization and the cost of care for VA HIV/AIDS patients found that VA has implemented a comprehensive HIV care program through case management that has led to dramatic shifts from inpatient care to treatment in outpatient settings. It also noted VA's use of improved therapies, access to all drugs, and national clinical education on treatment guidelines.

VA's large network of medical centers and clinics and its stable patient population provide an established system for large clinical trials, historical studies, drug treatment trials, and vaccine studies. In seeking better understanding of AIDS, VA also works closely with many other organizations. These include VA-affiliated universities, the National Institutes of Health (NIH), the Centers for Disease Control and Prevention, the Department of Defense, the NIH-funded Community Program on Clinical Research on AIDS, and the Food and Drug Administration. Increased collaboration and interaction among these organizations enhances opportunities to discover new and better treatments.

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