Testosterone replacement therapy in people with HIV

It is estimated that as many as 40% of HIV-positive men who are ill because of HIV have low levels of testosterone (hypogonadism). Low testosterone can result in decreased appetite, depression, poor metabolism of food, and sexual problems, including the inability to obtain and maintain an erection.

A blood test can show if you have low levels of testosterone and your doctor may prescribe either a short course of oral testosterone replacement therapy, testosterone patches, or testosterone gel.

Although testosterone cypionate is usually considered to be the male sexual hormone, it also occurs naturally in women. Testosterone patches have been examined as a treatment for wasting caused by HIV in women. It was found that weight and quality of life improved for some of the women, and the development of male characteristics was not reported.

Side-effects from testosterone replacement therapy are rare, but can include the shutting down of natural testosterone production, shrinking of the testicles, hair loss, increased sexual desire, and aggression. In women, male characteristics, such as the deepening of the voice, and facial hair may develop.

Steroid increases lean muscle mass in HIV-positive men, but has side-effects

Use of the steroid oxandrolone is associated with significant gains in weight and body cell mass in HIV-positive men who had experienced HIV-related wasting, according to an American study.  However, although the steroid increased muscle mass, it did not improve endurance and caused side-effects, including an increase in levels of ‘bad’ LDL cholesterol and elevations in liver enzymes.

Unintentional loss of just 3% of body weight has been associated with poorer survival in HIV-positive individuals. Although the use of antiretroviral therapy has led to a significant decrease in the prevalence of unintended weight loss, it is still common, even amongst people taking HIV treatment.

Diet and appetite stimulation can help increase weight in people affected by HIV-related wasting, but most of the gains of weight occur in the form of fat, and stores of body fat are not correlated with improved survival in HIV-positive individuals. Some small studies have shown that anabolic steroids can increase body weight and muscle mass in HIV-positive patients. To further investigate the benefits of treatment with anabolic steroid therapy, investigators designed a double blind placebo controlled trial in which men with HIV-associated wasting were randomised to receive a placebo or one of a 20mg, 40mg, or 80mg daily dose of the oral steroid oxandrolone. The investigators measured changes in the patients’ weight, body composition, endurance, and also conducted laboratory tests to assess the safety of steroid treatment. For the first twelve weeks, the men were provided with blinded treatment. At the end of this period, all the men were given the option of receiving an open-label 20mg daily dose of oxandrolone for a further twelve weeks.

The study was conducted between the autumn of 1996 and the summer of 1998. Treatment with antiretroviral drugs was not a prerequisite for entry to the study, but if an individual was taking anti-HIV treatment, they were required to have been taking a stable regimen for at least six weeks. The investigators do not state how many patients were taking anti-HIV therapy, nor do they analyse their results according to the use of antiretrovirals, making it difficult to determine the applicability of these results in patients experiencing HIV-related wasting despite antiretroviral therapy.

A total of 262 men were recruited to the study. CD4 cell count was comparable across the four arms of the study at approximately 250 cells/mm3, as was viral load at approximately 120,000 copies/ml.

Body weight increased significantly in all arms of the study, including the placebo arm during the double blind phase (p < 0.014). Body cell mass also increased in all arms of the study during this phase. However, when the investigators subjected their results to further analysis, they found that patients who took the 40mg dose of oxandrolone had significantly greater increases in body weight at weeks two, four, eight and twelve than those individuals who received a placebo (p < 0.004). Although patients receiving the 80mg dose of oxandrolone had significantly greater weight gains than patients on the placebo at weeks four and eight, this was not the case at weeks two or twelve.

In addition, the investigators found that patients treated with the 40mg (p = 0.0049) and 80mg (p = 0.0002) doses of oxandrolone experienced significant changes in body cell mass compared to patients who received the placebo.

Treatment with the steroid did not, however, lead to any improvement in endurance.

The investigators noted that levels of AST and ALT liver enzymes increased during the first four to eight weeks in patients receiving the 40mg and 80mg doses of oxandrolone. What’s more, they found a dose-related increase in the incidence of moderate-to-severe liver abnormalities in people taking the steroid. This was diagnosed by laboratory tests looking at AST, ALT, bilirubin, and uric acid levels. Analysis also showed that people treated with the 40mg and 80mg doses of the steroid were significantly more likely than those taking the placebo to experience an increase in their ‘bad’ LDL cholesterol (p < 0.017).

On completion of the twelve-week double-blind phase of the study, all the patients were offered the option of remaining on the study for a further twelve weeks and receiving an open label 20mg oxandrolone dose a day. By the end of this period, there were no differences in weight between patients and liver function ceased to be significantly different from baseline.

“Oxandrolone treatment was associated with significantly greater body weight gain above baseline than with placebo. A major portion of this weight gain occurred in the lean body compartment”, comment the investigators, who note that theirs was “the largest randomized placebo-controlled trial of an androgen in patients with HIV-associated weight loss.”

Although the investigators note that treatment with the steroid was generally “well tolerated” they note that over 5% of patients had moderate or severe increases in levels of liver enzymes and that “LDL levels decreased and HDL levels increased.”

They recommend “further studies…to determine the efficacy of oxandrolone in improving muscle strength, physical function, and health-related quality of life in HIV-infected patients with weight loss.

Human Growth Hormone Being Used in AIDS patients

Serostim, a form of recombinant HGH  is being used to reverse the pernicious form of weight loss seen in later stage AIDS, called "wasting."

Wasting is different than the loss of weight and fat that comes from under eating, this wasting also occurs in later stages of cancer. Wasting is the unintentional loss of weight in which the lean muscle, the body mass, the bones and the body organs are all withering away. Many experts believe this loss of lean body mass contributes to immune dysfunction and makes it harder for AIDS patients to fight off life-threatening infections. The wasting process itself, if it goes beyond about 33% of ideal body weight, is incompatible with life, as was seen in concentration camp victims of World War II.

A number of medical centers took part in a study of 178 patients with AIDS-associated wasting, which is defined as having lost at least 10% of body weight. The patients who received growth hormone therapy gained an average of 6.6 pounds of lean body mass while losing an average of three pounds of fat after three months of treatment. The therapy also resulted in an improvement of their endurance and quality of life.

Dr. Schambelan, of UCSF says "At the moment there isn't another therapy in the late stages of AIDS that has had this kind of effect on the lean body mass." "There are therapies that can increase weight, such as an appetite stimulant called megestroacetate, but that weight gain tends to be primarily fat. The advantage of growth hormone is that it causes lean body mass to increase." Dr. Schambelan says that some of the patients are still coming in, even though the original study ended three years ago. "Obviously these are the people who are still alive and doing well and the people who didn't do well are no longer there, so you can't talk about the average effect. I think that the anecdotal experience is that for the people who continue to take the drug, who continue to eat, and don't get serious opportunistic infections, they have had a very robust response. The medication has increased the benefits. The gain in lean body mass they had in their three months of the study has doubled or tripled over the next year or two."

 Although human growth hormone does not cure AIDS, there is some evidence that it may lengthen the life of AIDS patients. The increase in lean body mass may make the AIDS patient less vulnerable to infections. When given with antiviral agents such as AZT, human growth hormone did not cause any increase in the amount of HIV. In fact, human growth hormone has been shown to stimulate the formation of new red blood cells, which are depleted by AZT.

Even more exciting, human growth hormone also appears to reduce the incidence of AIDS associated infections, such as polycystic pneumonia and Kaposi's sarcoma. It can rejuvenate the immune system; if it can actually strengthen the ability of HIV+ patients to resist infectious diseases it may improve both the quality and the quantity of their lives.

HIV causes structural heart disease

Researchers from Spain have shown that HIV causes structural heart disease. These findings support the introduction of cardiovascular screening for all HIV patients, particularly those who have a positive viral load.

"It is well known that patients with HIV have a high incidence of structural heart disease (mainly diastolic dysfunction and pulmonary hypertension) as measured by echocardiography but the reason is not clear. We decided to conduct a study to evaluate whether the stage of HIV or the detectable blood viral load were related to the degree of heart disease."

The Centers for Disease Control and Prevention (CDC) estimates that there are 1,144,500 people aged over 13 living with HIV in the US.

For the study, researchers analyzed data from 65 HIV patients, with an average age of 48. All the participants reported shortness of breath - dyspnea - which was graded as greater than class II on the New York Heart Association (NYHA) scale.

According to the Heart Failure Society of America, the NYHA scale is used by physicians to determine the stage of heart failure in patients and focuses on the patient's symptoms in relation to their daily activities and quality of life.

It ranges from class I with mild symptoms through to IV, where symptoms are severe and patients are unable to perform any physical activity without discomfort. This study focuses on classes III and IV, where patients display moderate to severe symptoms.

Participants' HIV stage was determined by the CD4 (T-cells) count, their susceptibility to opportunistic diseases and their viral blood load, tested by determining the number of virus particles, or copies, within a milliliter of blood.
AIDs.gov explains that while there is no "normal" viral load, as people who are not infected have no viral load, it is considered "undetectable" if the test measures are less than 40-75 copies in 1 milliliter of blood.

Patients were also given a transthoracic echocardiogram to see if they had structural heart disease (ventricular hypertrophy, systolic or diastolic dysfunction or pulmonary hypertension). Cardiovascular risk factors, such as diabetes, hypertension, smoking status and renal failure, were also assessed.

The researchers found that almost half of the patients (47%) had some type of structural heart disease, usually left ventricular hypertrophy, left ventricular dysfunction, pulmonary hypertension and signs of right ventricle failure.

Anabolic steroids help people with HIV put on weight and muscle mass

People with HIV who are treated with anabolic steroids to prevent AIDS wasting may realize modest gains in weight and muscle mass, a new review shows.
The review covered 13 studies of adults age 24 to 42 with HIV, 294 of whom received anabolic steroids for at least six weeks and 238 of whom received placebo. The average weight increase in those taking anabolic steroids was nearly three pounds.

“The magnitude of weight gain observed may be considered clinically relevant,” said lead author Karen Johns. “One hopes there would be greater weight gain with the long-term use of anabolic steroids; however, this has not been proven to date in clinical trials.”

AIDS wasting, which leads to significant weight loss in people with HIV, causes severe loss of weight and muscle and can lead to muscle weakness, organ failure and shortened lifespan. Researchers have long sought to reverse this common, destructive effect of HIV with mixed success.

The wasting stems from loss of the body’s ability to grow muscle and from low levels of testosterone.

Anabolic steroids are synthetic substances similar to the male sex hormone testosterone that promote growth of skeletal muscle and the development of male sexual characteristics.

Although most recently in the news for their misuse by professional athletes, anabolic steroids have legitimate medical application for men with low testosterone and people with certain types of anemia. Two anabolic steroids available in the United States, nandrolone decanoate and oxandrolone, have been used to help increase weight and muscle mass in small studies of people with wasting.

Conversely, anabolic steroid use has been associated with increased rates of HIV in those who share needles or use nonsterile needles when they inject steroids.

In the review studies, anabolic steroids were administered to patients either orally or by injection. The main side effects were mild and included abnormal liver function tests; acne; mild increase in body hair; breast tenderness; increased libido, aggressiveness and irritability; and mood swings — all common side effect of anabolic steroid use.

“The risks and side effects of taking anabolic steroids long-term are certainly of concern,” Johns said. “We were unable to assess these risks in our review due to the short duration of treatment in the studies.”

Wayne Dodge, M.D., the HIV/AIDS program director at the Group Health Cooperative in Seattle, suggests that clinicians should obtain blood testosterone levels, “if an HIV-infected individual has had significant weight loss, significant fatigue or muscle wasting, and particularly if associated with a significant decrease in libido and erections. If [testosterone] is in the low or low-normal range then a trial of [steroids] could be tried. The individual and the clinician should decide what result would constitute a successful trial: weight gain of 15 pounds, a 30 percent improvement in sense of well-being [or] a successful erection once a week.”

The reviews authors conclude that further studies are needed to determine if increase in weight leads to improved physical functioning and quality of life, and ultimately increased survival, as well as the potential for serious side effects, especially with prolonged use.

AIDS & HIV: Treatment & Prevention

While 1.1 million Americans currently live with HIV/AIDS, the incurable virus is no longer a quick death sentence and has become a chronic, manageable condition.

Symptoms & Complications

When a person is first exposed to HIV, they may show no symptoms for several months or longer. Typically, however, they experience a flu-like illness that includes fever, chills, headache, fatigue, muscle aches and enlarged lymph nodes in the neck and groin areas. This early illness is often followed by a “latency” phase where the virus is less active and no symptoms are present, according to the U.S. Department of Health and Human Services. This latent period can last up to a decade or more.

As HIV progresses into full-blown AIDS, it severely damages the immune system, causing a wide variety of symptoms such as:

• Rapid weight loss or “wasting”
• Extreme fatigue
• Recurring fevers and night sweats
• Prolonged gland swelling
• Prolonged diarrhea
• Sores in the mouth, genitals or anus
• Pneumonia
• Skin blotches
• Depression, memory loss and other neurological effects

According to the U.S. Centers for Disease Control (CDC), untreated HIV is also linked to serious conditions such as cancer, liver disease, cardiovascular disease and kidney disease. 

Diagnosis & Tests

Since HIV/AIDS can set off so many other illnesses, it may be difficult initially to pinpoint the source. Typically, however, these illnesses appear in clusters over a short period of time, cluing patients and doctors into the presence of the virus. According to NIAID, two types of blood tests can confirm HIV/AIDS infection:

• ELISA, or enzyme-linked immunosorbent assay, which detects disease-fighting proteins called antibodies that are specific to HIV; and

• Western blot, which detects antibodies that bind to specific HIV proteins

After someone is first infected it may take weeks or months for the immune system to produce enough detectable antibodies in an HIV blood test. Ironically, an infected person’s viral load may be very high during this time, making the infection exceptionally contagious. Because of this, the CDC recommends routine HIV testing for all adolescents, adults and pregnant women, and advises that everyone between the ages of 13 and 64 should be tested at least once.

Conventional HIV/AIDS tests are sent to a laboratory for analysis and may take a week or more for results. A rapid HIV test is also available that offers results in about 20 minutes, but positive results from either type of test are confirmed with a second test.

Prevention

More than 56,000 Americans become infected with HIV each year, according to the U.S. Department of Health and Human Services. While some AIDS patients have been infected through blood transfusions during medical procedures, preventing infection usually depends on avoiding risky habits or behaviors that lead to exposure to the virus, which can be transmitted through blood, bodily fluids such as semen and infected needles.

Prevention measures include:

• Knowing yours and your partners’ HIV status
• Using latex condoms correctly during every sexual encounter, whether gay or straight
• Limiting the number of sexual partners
• Abstaining from injectable drug use
• Seeking medical treatment immediately after suspected HIV exposure, since medications can sometimes prevent infection if started early

It’s just as important to know the ways HIV cannot be spread, such as by:

• Saliva, tears or sweat
• Water or air
• Casual contact such as closed-mouth kissing or shaking hands
• Insects, including mosquitoes

Early HIV Treatment a Win-Win

A cost-effective way to help patients stay healthy and prevent virus transmission. Providing early antiretroviral drug treatment for recently infected HIV patients and their uninfected sexual partners is a cost-effective way to help patients stay healthy and prevent transmission of HIV, a new study finds.

The study, looked at HIV patients in India and South Africa. Some of the patients received early antiretroviral therapy while the start of treatment was delayed for other patients. HIV is the virus that causes AIDS.

During the first five years of the study, 93 % of those who received early antiretroviral therapy survived, compared with 83 % of those whose treatment was delayed. Life expectancy was nearly 16 years for those in the early treatment group, compared with nearly 14 years for those in the delayed treatment group.

During the first five years, the potential costs of infections - particularly tuberculosis - prevented by early treatment of HIV patients in South Africa outweighed the costs of antiretroviral therapy drugs, suggesting that the early treatment strategy would reduce overall costs.

This was not the case in India, where the costs of treating HIV-related infections are less. Even so, early antiretroviral therapy in India was projected to be cost-effective according to established standards, the researchers said.

They also found that across patients' lifetimes, early antiretroviral therapy was very cost-effective in both countries. While most of the benefits of early treatment were seen in the HIV-infected patients -- fewer illnesses and deaths -- there were also added health care and economic cost savings from reducing HIV transmission, according to the study.

"By demonstrating that early HIV therapy not only has long-term clinical benefits to individuals but also provides excellent economic value in both low- and middle-income countries, this study provides a critical answer to an urgent policy question," study corresponding author Dr. Rochelle Walensky, of the Massachusetts General Hospital Division of Infectious Disease. "HIV-infected patients live healthier lives, their partners are protected from HIV, and the investment is superb," she added.

Walensky, a professor of Medicine at Harvard Medical School, said the findings point to a need to "redouble international efforts" to provide early antiretroviral therapy to any HIV-infected person who can benefit from it. Her colleague, Dr. Kenneth Freedberg, director of the Medical Practice Evaluation Center at Massachusetts General, agreed.

"Some people have questioned whether providing early [antiretroviral therapy] to all who need it would be feasible in resource-limited countries," he said in the news release. "We've shown that in countries like South Africa, where it actually saves money in the short-term, the answer is 'yes.' We believe that continued international public and private partnerships can make this true in other countries as well."

Freedberg said such an investment could bring about dramatic decreases in infections and illness that could save millions of lives over the next decade.

Multivitamins May Help Fight HIV Progression

But supplements tested only on those who hadn't started medications

New research from Africa suggests that basic multivitamin and selenium supplements might greatly lower the risk that untreated people with the AIDS virus will get sicker over a two-year period.

It's not clear how patients who take the vitamins and mineral might fare over longer periods. And the impact of the study in the United States will be limited because many Americans diagnosed with HIV, the virus that causes AIDS, immediately begin treatment with powerful medications known as anti-retroviral drugs. Those in the African study hadn't yet begun taking drugs to keep the virus at bay.

Still, "it is incredibly useful to find new strategies to delay the progression of HIV disease," said Dr. Jared Baeten, an associate professor of global health at the University of Washington in Seattle who's familiar with the findings. "Not every HIV-infected person is immediately willing, or able, to initiate anti-retroviral therapy. Inexpensive, proven treatments ahead of starting anti-retroviral therapy can fill an important role."

At issue: Do HIV-infected people benefit from nutritional supplements? Previous research has suggested that even well-fed people infected with HIV may not properly process nutrients in food, said study author Marianna Baum, a professor of dietetics and nutrition at Florida International University's Stempel School of Public Health.

The researchers wondered whether the immune system would get a boost if patients who hadn't yet begun anti-retroviral treatment took nutritional supplements. No study had looked at this before, Baum noted.

For the study the researchers divided nearly 900 HIV-infected patients in the African country of Botswana into several groups. Some took a placebo, a sugar pill with no active ingredients. Others took a multivitamin including B, C and E vitamins. Another group took the multivitamin along with supplements of the mineral selenium, and still others took only selenium.

None of the treatments had a noticeable effect except the combination of multivitamin and selenium. After adjusting their statistics so they wouldn't be thrown off by various factors, the researchers reported that those who took the combination were about half as likely to show signs over two years that their infection had progressed toward AIDS as those who took the placebo.

Overall, the risk that the disease would progress over the two years of the study was fairly low: 32 of the 217 who took the placebo suffered progression of the disease, she said, compared to 17 of the 220 who took the vitamin/mineral combination.

Baum didn't have information about the costs of the supplements, but she said they are low. In the United States, supplements that contain many vitamins and minerals can cost just pennies a day.

The supplements appeared to have no side effects, said Baum, who recommends that people newly diagnosed with HIV begin taking multivitamins. They seem to boost the immune system, she said. The selenium supplements, in particular, may provide enough of the mineral that the virus isn't able to hog it, she said.

Baeten cautioned that not just any multivitamin will do. "The results of this study appear to illustrate that it is not just any supplement," he said.

"Only the combination of vitamins plus selenium was effective," Baeten said. "For U.S. patients, this latter point is relevant, as there's a huge variety of supplements available. I would suggest talking with a doctor before taking any supplements."

He added that the study doesn't detract from the crucial importance of anti-retroviral drug treatment.

Researchers next want to see if the supplements help patients already taking anti-retroviral medications, study author Baum said.

Researchers Block Replication of AIDS Virus

A multidisciplinary team of scientists from Spanish universities and research centres, among which is the University of Valencia, has managed to design small synthetic molecules capable of joining to the genetic material of the AIDS virus and blocking its replication.

This achievement has been obtained for the first time in the world by a group of researcher led by José Gallego from Universidad Católica de Valencia "San Vicente Mártir." The University of Valencia, the Príncipe Felipe Research Centre, and the Instituto de Salud Carlos III have participated.

The newly designed synthetic molecules inhibit the output of genetic material of the virus from the infected cell nucleus to the cytoplasm, thus the virus replication is blocked and avoids the infection of other cells. The genetic material of the AIDS virus, or HIV-1, is formed by ribonucleic acid (RNA), and encodes several proteins that allow it to penetrate the human cells and reproduce within them. The new virus inhibitors, called terphenyls, developed by this group of scientists, were designed by computer to reproduce the interactions of one of the proteins encoded by the virus, the viral protein Rev.

In this way, the terphenyls join Rev's receptor in the viral RNA, preventing the interaction between the protein and its RNA receptor. This interaction is necessary for the virus genetic material to leave the infected cell nucleus and, thus, it is essential for the survival of HIV-1. The fact that the terphenyls block the virus genetic material output of the cell prevents the infection of other cells.

This discovery is the result of a close collaboration between three research groups throughout several years. Thus, the scientists of the Universitat Católica de Valencia were in charge of the computational design and verified experimentally that the terphenyls were capable of joining the Rev receptor in the viral RNA and inhibit the interaction between this RNA and the protein.
For its part, the molecules were synthesised in professor Santos Fustero's organic Chemistry laboratory in the Príncipe Felipe Research Centre and the University of Valencia. Also, through experiments with cells infected by the virus, the group of José Alcamí in the Instituto de Salud Carlos III demonstrated that the inhibitors block the replication of the HIV-1 and inhibit the function of the Rev protein, confirming this way the validity of the models generated by computer.

Traditionally, pharmaceutical companies have focused on the development of medicines that act on target proteins, as the approach to the receptors made out of RNA is considerably complex.

Although several natural antibiotics act at the bacterial ribosomal RNA level, up to now designing by computer a new synthetic chemical entity capable of joining RNA target and have a relevant pharmacological effect was not possible. The terphenyl structures identified in this research could open new ways to approach other therapeutic targets formed by nucleic acids.
On the other hand, the infection by HIV affected 34 million people worldwide in 2010, according to the World Health Organisation (WHO). The emergence of resistance to the current antiretroviral therapies and the lack of an effective vaccine highlight the necessity of identifying the new medicines that act on other virus targets. Rev protein constitutes one of this alternative targets, but so far they it has not been possible to develop antiviral agents based in their inhibition.

The results of this research have been the objectives of a patent application, and the three laboratories involved in the research keep their collaboration with the objective of improving the pharmacological properties of new Rev inhibitors.

Untreated HIV Carriers Transmit Resistant Viruses

Human-Immunodeficiency Viruses that resist AIDS medicines are primarily transmitted by people who are not actually undergoing treatment. In order to prevent a spread of the resistant viruses increased efforts in prevention and early diagnosis of new infections are needed, as concluded by the Swiss HIV Cohort Study that is supported by the Swiss National Science Foundation (SNSF).

Around one in every ten newly infected HIV carriers in Switzerland has viruses that are resistant to at least one of the three classes of drugs used to treat AIDS. Contrary to previously held assumptions, resistant viruses are primarily transmitted by people who are not yet receiving treatment, according to the reports in "Clinical Infectious Diseases" from the researchers headed by Roger Kouyos and Huldrych Günthard at Zurich University Hospital.

Reconstruction of transmission chains - In their molecular epidemiological analysis of 1674 male carriers of HIV who had sex with other men, the researchers demonstrated resistant viruses in 140 patients. The research group reconstructed the transmission chains of these viruses on the basis of the patients' estimated infection dates and the degree of genetic relatedness of their blood-borne viruses. Most of the transmission chains commence in HIV carriers who were not yet undergoing treatment at the time at which the resistant viruses were transmitted.

"We were astonished to note that the resistant viruses are primarily brought into circulation by untreated people," said Günthard. "Previously we had assumed that the resistant viruses came from patients for whom treatment had failed as resistances were produced while treatment was ongoing."

Early diagnosis is vital - The principal role of untreated HIV carriers in the transmission of resistant viruses means that combating these resistant strains is not solely reliant on optimised treatment, but also on preventing transmission by people who are not undergoing treatment. Prevention and early detection of newly infected persons are particularly vital in this respect. "In contrast to other tests, such as that for hepatitis, the HIV test requires that permission is obtained from the patient," explained Günthard. Since many doctors are reluctant to discuss their patients' sexuality with them openly, many infections are not discovered until much later than they could and should have been. While progress in medicine has robbed AIDS of its deadly effect, Günthard went on to stress, "there is still a great deal to be done."

The Swiss HIV Cohort Study - The aim of the study, which started in 1988, is to better understand HIV infection and AIDS, and improve the treatment of patients. All of Switzerland's specialist HIV clinics (Basel, Berne, Geneva, Lausanne, Lugano, St. Gallen and Zurich) collect data on treatment and the progress of the disease. Currently over 8,800 people are taking part in the Swiss HIV Cohort Study, of whom almost one third are women.