A publication of Vietnam Veterans of America, Inc. ®
An organization chartered by the U.S. Congress
December 1999/January 2000
An Update on The Department of Veterans Affairs HIV-AIDS Program
Dr. Lawrence Deyton, the director of AIDS Services at the Department of Veterans Affairs, received his master’s degree from the Harvard School of Public Health and his M.D. from the George Washington University School of Medicine. He is a member of the faculty of Johns Hopkins University School of Medicine and has been an AIDS researcher for the last 15 years. He has won many awards, including the U.S. Public Health Service Special Recognition Award.
Dr. Deyton recently sat down with Jacqueline Rector, VVA’s national PTSD/Substance Abuse Committee chair, and spoke about AIDS, HIV, veterans, and the VA. The VA is the largest single provider of HIV care in the United States. In 1998, over 18,000 veterans received HIV care at VA facilities. The VA runs the nation’s largest direct HIV testing program. With some 50,000 AIDS tests administered annually, the VA has amassed the largest clinical HIV database in the nation. There is an AIDS coordinator at every VA facility. Cindy Dumas and Patricia Martin, nurses and members of Chapter 454 in Louisville, Kentucky, helped direct this interview.
The VA is the largest single provider of HIV care in the United States. In 1998, over 18,000 veterans received HIC care at VA facilities. The VA runs the nation's largest direct HIC testing program. With some 50,000 AIDS tests administered annually, the VA has amassed the largest clinical HIV database in the nation. There is an AIDS coordinator at every VA facility.
VVA: Are veterans at higher risk for HIV than other populations?
Deyton: Yes, I think that veterans are at higher risk, particularly where this epidemic is today in America. When HIV started, we saw it first in gay and bisexual men, but then quickly we learned that injection drug use and blood transfusions were also risk factors.
Today, the predominant mode of transmission is injection drug use or sex with someone who has had injection drug use. We know that persons who are homeless or who have serious mental illness or PTSD are at an increased risk for HIV.
We also know that veterans are disproportionately represented among the homeless and have a higher risk of PTSD, substance abuse, and chronic mental illness. Therefore, veterans are at higher risk of being exposed to HIV.
VVA: Early treatment is very important, isn’t it?
Deyton: Yes. We have proven in clinical trials that giving effective medicine early in treatment extends life. HIV works like this. It gets into the system. It attacks the immune cells. It attacks the body’s own ability to fight other infections. We have proven that when effective medicine is given early, it helps to prevent the immune system from getting damaged so badly that someone gets sick and dies.
We haven’t had effective drugs long enough to know how long that lasts, but we do know that if it is given earlier, people are kept alive longer. So we are still learning how to use the medicines, and we know that early treatment helps.
VVA: Is it true that there are many different types of tests?
Deyton: Yes, there are all kinds of testing available, through your doctor, public clinics, and anonymous testing centers where people can go if they don’t want their name associated but want to get the results. Different states have different policies, but for the most part, it is very available.
VA is actually the largest single HIV testing organization in the nation. We give approximately 50,000 HIV tests yearly. So, we have very standard policies for HIV testing. Anytime a veteran comes in and wants an HIV test, he or she meets with an HIV test counselor and gets educated about HIV and the risk factors. After the results return, the veteran meets with the same counselor again and gets the test results. Regardless of what the answer is, they also get the counseling again about risk reduction, safer sex, and such, to help limit the spread of disease.
VVA: What is the difference between being HIV-positive and being diagnosed with AIDS?
Deyton: Being HIV-positive means that a person has been exposed to the virus and his/her body has mounted an immune response to it. We do an antibody test. Antibodies are part of the immune system that are built to fight infections. If the body has built the antibodies to fight HIV, that means the person has been exposed. When we see the antibodies there, we know the virus is there, too. So, that is HIV-positive.
After some time with HIV infection, the immune system gets progressively damaged. Without any treatment, this can take eight to ten years, and a person is at increased risk of specific kinds of infections. When a person gets one of these specific infections, that tells us that the immune system is not working. That’s when someone has AIDS.
There is a list of thirteen or fourteen infections or malignancies that are defined as having AIDS. AIDS really is a definition that the Centers for Disease Control uses to represent the late stage of HIV infection.
VVA: Is it possible that an HIV-positive person never gets AIDS?
Deyton: The question really is: Somebody who is HIV-positive has the virus, but they never really get sick.
We have documented that quite a lot. It is kind of rare, but it represents someone infected with the virus, but for some reason his immune system is doing a good job containing it. There is something about his or her immune system that is better than average, and he or she is containing the virus so that it doesn’t continue to damage the immune system. The virus is there, but the immune system stays strong.
Or, the HIV virus is multiple families of viruses, and there are some of them that are defective, so someone might have been infected with the virus, and it gets in there and it is positive when the test is being run, but it is not doing any damage. It is not strong enough to cause any damage. We have documented cases of these.
We are learning a lot from those cases to help us understand how to build a vaccine for HIV. What is going on in a person’s immune system that is containing the virus might be something we could mimic with a vaccine. Or maybe the virus is defective, and there is something that we could cause to happen to fight the virus. We are working on all of that.
Most importantly, someone who is HIV-positive can stay healthy and not progress to AIDS by starting effective medicines.
VVA: What is the life expectancy for someone who is HIV-positive?
Deyton: It has actually changed dramatically in the last several years. You have heard, no doubt, that there are much improved therapies for HIV. About two or three years ago, the average life expectancy for someone with HIV--whose immune system was damaged, but not too damaged--was maybe eight or nine years. Someone already diagnosed with AIDS, that is, their immune system was already damaged, had a life expectancy of maybe two years.
However, with the new therapies--if someone can take the therapies, for they are not easy to take--if they do the job, short-term estimates show that the life expectancy for someone who has HIV infection (and whose immune system is not yet very damaged) is twenty years.
For somebody who is already sick--that is, who already has AIDS--and who starts taking these new therapies, life expectancy is now eight to ten years. This is good short-term news. However, this is a very important issue. It means that, fortunately, people are living longer, but it also means that we will have many more people under care because they are not dying, and this care is expensive.
It’s complicated. We have already seen this in our data, that the actual number of veterans under care for HIV is beginning to climb. It is because we are being successful, and we have gotten all of the therapies to them. It is good news: We are keeping veterans alive a lot longer with this chronic disease, and many of them are going back to work and having productive and happy lives.
VVA: What is the co-infection rate for hepatitis C and HIV?
Deyton: It is disturbingly high. We have done several studies at individual VA Medical Centers. Since the risk factors for hepatitis C and for HIV overlap, you would expect that there would be a high co-infection rate. At one medical center, about 35 percent of the veterans in the HIV clinic also were diagnosed with hepatitis C. At another medical center, I think it was 23-28 percent.
It is not just that they have one disease and another disease. The two diseases likely interact with each other. We are beginning to see that people with HIV and hepatitis C may progress more rapidly than people who don’t have HIV. We also are trying to find out what happens with the HIV, to see if that goes any faster or not. We don’t know the answers yet, but I am working with the people doing the hepatitis C work, to try to learn more about this so we can do something about it.
VVA: Does the VA pay for all medications used to treat veterans with AIDS?
Deyton: Absolutely. Every licensed HIV drug is on the national formulary. It is my job to make sure that that happens. I am in very close contact with the pharmaceutical industry, so I know when drugs are about to be licensed. I work with them and the VA’s Pharmacy Benefits Management Group, get the paperwork done, so that literally at the point that a drug is approved by the FDA, I am submitting the paperwork to get the drug available on the formulary. Today, every single licensed drug is available.
VVA: Are there new medications being tested for treatment of AIDS?
Deyton: Yes. VA is heavily involved in that. Most of this work is being sponsored by drug companies. There are lots of new drugs being tested and new combinations of drugs, and so a lot of progress is being made. VA is at that table, involved with the drug companies and with the National Institutes of Health in helping to test these new drugs.
If a veteran wants to participate in a trial, he or she should be able to. I have tried to make sure that those options are available. They are optional, certainly, because there are lots of people who don’t want to participate in the trials. But, I think having good research programs in our HIV clinics and medical centers can only improve the care that veterans get.
VVA: What other recommendations, besides medication, are important for HIV-positive individuals or those with AIDS?
Deyton: The important recommendations are: If you are a person with HIV infection and taking medicine, take your medicine, take it as prescribed. The second important recommendation: Practice safe sex and don’t share needles.
VVA: How close are we to developing a vaccine to prevent AIDS?
Deyton: A lot of work has been done on understanding what a vaccine would need to do to help prevent AIDS. We are not there yet. There is a lot of basic science work that needs to go on. VA is involved in much of that, but we are not close yet. I don’t think there is a vaccine right around the corner. The only answer now is prevention. Tell your children and parents, tell your brothers and sisters, tell your friends and neighbors: we are all at risk if we practice unsafe sex or share needles.
VVA: What research are you currently involved in relating to the HIV virus?
Deyton: It is my belief that VA is a natural laboratory in which to do really excellent HIV research. We have a very large number of patients we care for in this system who have HIV. We have a very large number of senior, world-class HIV researchers in the system, although people don’t think of them as being in the VA, because they always publish and are known through their academic affiliations. I think that we are sitting in a perfect position to take a leadership role in HIV research.
There are a couple major research projects that we have launched since I have come to VA. One is a very large grant application that we submitted to the National Institutes of Health to get money to allow us to support a national network to do HIV clinical trials. It would give veterans access to participate in research, if they want to. This could happen right in the medical center where they receive their care.
We are also developing applications, again to NIH, to do HIV vaccine research. In addition to testing for a vaccine to prevent HIV infection, we have another application to look at how to prevent HIV infection, not using a vaccine, but through behavioral interventions, such as substance-abuse counseling, safer sexual practices, and using things like microbicides. Microbicides are used in sex like a lubricant and would actually kill the HIV that might be in infected semen or vaginal secretions. We have a role in that research. We also have launched several trials that are supported solely by the pharmaceutical industry, using the VA again as a network to do research to help the veteran with new HIV drugs and therapy.
E-mail us at TheVeteran@vva.org