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  Treatment of Individuals with HIV Infection At Herdecke Hospital
  

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By: Christof Schnuerer, M.D.
pgs. 8-23.doc

Treatment of Individuals with HIV Infection At Herdecke Hospital Experiences, Hypotheses, Treatment Strategies (Original title: Behandlung von HIV-Betroffenen im Gemeinschaftskrankenhaus Herdecke. Merkurstab 1995; 48: 217-31. Record of a lecture (Medica, Stuttgart 18 Nov. 1994). The record has been extended and an introduction added. English by A. R. Meuss, FIL, MTA.) Christof Schnuerer JAM Vol. 12, Nr. 3

Abstract
From 1985 to Jan. 1995 a total of 117 HIV and AIDS patients (265 admissions) received inpadent care at Herdecke Community Hospital (HCH). Primary reason for admission was, with few exceptions, advanced stage of the disease (> B/2 in current CDC classification). Selected data of a retrospective analysis covering 70 patients treated between 3/87 and 11/92 are presented and discussed.

The conclusions drawn from our material are considered in relation to the current status of AIDS research, after which the question is considered: how disease may be defined in terms of interaction between pathogen (external factor) and host (self determination). An attempt is made to reduce the many different conditions of human life to basic phenomena, one of these being polarity and the balance created between extremes. Polar phenomena can be perceived at different levels of life (micro, meta and macro levels). A polar phenomenon at the meta level, the functional threefold order of the human organism, first established by R. Steiner, is considered in some detail. AIDS is then considered from this point of view, with treatment strategies derived. Taking this approach further, critical questions arise concerning chemotherapy, which is widely used to prevent opportunistic infections.

1. Introduction

The appearance of AIDS went hand in hand with a change in paradigm in Medicine(1) which was not entirely triggered, but certainly catalyzed, by AIDS. The "new disease" therefore marked a turning point in the history of medicine.

Pathophysiology is quietly leaving its classic models behind (e.g. Koch's postulates and Virchow's cellular pathology) and becoming a science of "messages". "Communication" or, rather, "failure of communication" between cells is the level where disease originates according to present ideas. Interest now focuses on information transmitters (messenger compounds, cytokines).

The disease model is, thus, coming close to the "composition of bodily fluids" again, though in the new way, and we have a kind of synthesis of humeral and cellular pathology.

This approach will (need to) advance from the organization idea to one of organism, with the latter taken as a purely spiritual concept. Leaving the spirit out of account in medical research - which has been done most successfully over the last 100 years - is reaching its limits in psychoneurotmmunology today and in investigations concerning quality of life and coping with illness. Primarily coming from the field of oncology, the above-mentioned questions are coming up everywhere in medicine and have been given a new dimension with the AIDS issue.

These are milestones on the road from thinking in a single dimension to using more complex approaches. Man is increasingly seen as a multifarious entity whose state of health or disease reflects concurrent processes and relationships between different levels of existence. Anthroposophic medicine offers both an anthropologic model ("Anthroposophy") and practical methods and processes that can be followed.

Other attempts to develop a model of the human being that is closer to reality than the somatic model are far less comprehensive. Thus the biospychosocial model - to mention an approach that is widely accepted in the Anglo-Saxon world - has been called "metaphysics without method,"(2) among other things because of its inadequate anthropologic background. (Another, more descriptive, way would be to say it lacks a real image of man). This clinical model, introduced by Engel in 1977,(3) claims to be holistic and seeks to include the psychologic and social levels in treatment, making them equal to the somatic level.

Considering these developments we may say that in various respects the spirit of the age in medicine has come closer than ever before to the anthroposophic approach. This may be taken as an opportunity and, indeed, a challenge to anthroposophic practitioners. It is important to realize that AIDS acts as an indicator in this context, and the subject needs to be taken up on a broad scale.

Below an attempt is made to develop a treatment strategy for HIV and AIDS patients. It is published with the aim of contributing to the discussion rather than offering a systematic or exhaustive study of the subject. Nor is it intended to report clinical results but primarily to present a method and the experiences on which it is based.

It is important to note that this is a record of a lecture given as part of a training course in anthroposophic medicine (emphasis on threefold nature). Simplification, where it occurs, was designed to meet the needs of the target group. These passages have nevertheless been largely left unchanged, partly for didactic reasons.

2. Clinical Background: Data and Conclusions
Between 3/87 and 1/95, a total of 117 HIV-infected patients were admitted to 


The case records of inpatients treated from 3/87 to 1 Dec. 1992 (n = 70) were analyzed in 1993. Selected data are given in Tables 2 and 3 and Fig. 1. (Full documentation and two individual case studies have been published elsewhere).(4)

Distribution between affected groups (Table 2) in our material agreed largely with that given by the German Federal Department of Health (BGA). The same applies to age (36 years on average) and sex distribution.

Three differences should be noted, however:

1. The proportion of heterosexuals is distinctly higher in our sample.

2. The percentage of physicians (almost 8%, incl. one wife) is no doubt higher than usual.

3. A proportion of 71% of supraregional patients (compared to 45% in the rest of the department) seems worth noting.

Points 2 and 3 in particular suggest an atypical collective (special motivation?); the trend in recent years has been a definite increase in regional patients.

On first admission, immunosuppression was generally at an advanced stage, with T4 levels below 200/pl in 70% (Fig. 1). This marks the threshold for


routine prevention of opportunistic infections. According to the American CDC definition (valid from 1 Jan. 1993 but not adopted in Europe), this stage is classified under AIDS irrespective of whether an indicator disease is present.

Table 3 correlates the mean T4 cell count on admission with survival time.

It seems appropriate to comment on the relatively high proportion of patients who died during their inpatient period (7.1%). All of them died in the first 3 years of the period under investigation (3/87-11/92). Since then (until 1/95) we have merely lost one more patient on first admission, and that was in 8/93. The reduction in deaths on first admission is no doubt partly due to growing personal and general experience with AIDS (better range of treatments and management).

However, the selection of patients clearly had a major influence. Initially we admitted many patients who had largely been through all possible treatments and were in the terminal stage (3/5 of the deaths on first admission). Another patient consistently refused all active treatment, wanting only nursing care and human concern. One single patient with previously untreated acute AIDS and hemiparesis was profoundly unconscious on admission and died before diagnosis and treatment could be instituted. In retrospect, the rapid fatal end might perhaps have been prevented by immediately initiating the established high-dose treatment for toxoplasmosis (post-mortem examination was not possible). We were particularly affected by the above-mentioned fatal outcome (8/93). After a cholecystectomy the patient developed various mental disorders of a psychotic, catatonic and depressive nature. He had previously shown depressive tendencies and was under great stress psychosocially, and in the absence of other neurological or MRI findings the changes were interpreted as a reactive psychosis. Shortly before referral to the medical department (for further diagnosis and treatment) he unexpectedly went into cardiac arrest, and following reanimation survived for only a few hours. Histology of the brain showed diffuse cryptococcal encephalitis.

The case is described in such detail because it illustrates two basic problems in the treatment of HIV infections: (1) the diagnostic problem (established diagnostic criteria do not apply) and (2) a complex of neurologic, psychiatric and psychosocial intentional factors that may result in signs and symptoms being misread.

Our analyses agreed with the literature in showing a statistical connection between life expectancy and mean CD4 receptor-positive cell count.

More careful weighting did, however, show the predictive CD4 cell count to be absolutely unreliable in the individual case. Thus, we saw unexpectedly unfavorable development even with high T4 cells counts (e.g. 510, with 26 months survival). On the other hand, relatively long survival went hand in hand with low initial counts (e.g. 70, with 36 months survival).

Since the 9th International AIDS Congress in Berlin (1993), if not before, the phenomenon of often highly individual developments has been widely discussed as an important research issue. Interest focuses particularly on the conditions for "long-term survival" of people with HIV infection. (The definition of "long-term survival" in the literature varies).(5) Definition is, however, of secondary importance in the present context, so there is no need to go into it in detail.

More recent studies (e.g.(6)) appear to contradict the assumptions of earlier studies (e.g.(7,8)) and show that lifestyle, coping, anxiety and depression do not influence survival to the extent formerly assumed. Our observations have shown, however, that rapid progression was often connected with negative events in life (e.g. death of partner) and psychosocial stress (e.g. at work or at home). Conversely, we saw the condition stabilize if it proved possible to establish a stable therapeutic relationship and/or if psychosocial stress was reduced.

Our conclusions agree with those published by Fauci in Science in 1993 after more than 10 years of intensive world-wide AIDS research:(9) AIDS is more than just HIV infection.

AIDS is the consequence of a complex relationship between a person and environmental factors in the widest possible sense. The how and why of the relationship, from "transmission" to clinical manifestation, are conditions that have now been largely followed statistically, but their "nature", original causes and evolution essentially still need to be described.

Reduced to its basic phenomena, AIDS is a process between an individual (host) and (many and varied) external factors. One of these factors is evidently connected with a "mineral-like" life form consisting of little more than information (virus). If we want to go beyond mere observation, it must be permissible to ask what this "entity" has to do with the human being.

The relationship is clearly intimate, for not only does the virus depend on the human being for its survival (no animal model exists), but its information structures are closely related to human genes, with its integuments more or less a counter image of cell surfaces. Apart from anything else this entity has possession of the "security key" to the human immune system. (Such a process shows the close, complementary relationship between human and world, casting doubt on the idea of "chance" triggering a disease, even from the microscopic point of view).

The "pathogen" may almost be said to be intelligent and well informed in the way it has adapted to the state of present knowledge, and is, therefore, able to resist treatment. (In a similar context Dumke(10) quotes Adolf Portman who, with reference to the pathogen causing rabies, speaks of the "extraneous knowledge" held by microorganisms, calling such properties "truly demonic"). Yet many of the factors which trigger disease are directly or indirectly dependent on man (Table 4) and, therefore, open to treatment strategies in the widest sense.

Which are the effective methods available today? Prevention is acknowledged to be the most effective individual treatment for AIDS. It depends entirely on the individual, however, on his behavior and the way he deals with psychological conditions (desire for pleasure - sexuality - addiction).

The experts generally agree that the world-wide struggle to deal with the pandemic can only be won if the following "social diseases of our time" can be limited:

1 Social imbalance (poverty on one hand and pointless riches on the other, with disease rife at either extreme)

2 World-wide desolation in education systems

3 Epidemic spread of addictive structures.

The current situation forces us to consider the virus issue as secondary when it comes to treatment. (Hopes of a vaccine that would really change the situation are illusory; even if it were to be unexpectedly available in a few years, it is unlikely to have any real effect on the evolution of the pandemic).

This point of view justifies the objections (raised by a number of authors, P. Duesberg(11) in particular) to monocausal viral genesis or simplification of causality. Duesberg's emphasis on drugs and medicaments as causal factors(12) may then appear in its right light - on a different level, of course, from the biased and simplistic views presented by virologists not familiar with the clinical situation.

3. Initial Hypotheses for our own AIDS Strategy
Our own approach to research and treatment bases on the many indications Rudolf Steiner gave concerning the outstanding role the host plays in infection.(13)

Our analyses of causes and search for suitable treatments has, therefore, always concentrated on the human being. In our approach to treatment we were thus able to abandon the limiting view of viral origins and treat antiviral strategies (e.g. AZT, DDI, DDC) with pragmatic and critical distance. (This made it easier in the early days of AZT euphoria to base ourselves on our own clinical experience with the substance and not just on statistical successes reported with surrogate markers. More recent trials (e.g. CONCORD) justify this approach).

In other words, we focused less on the microscopic causes and more on the macroscopic phenomena. (Albonico asked for the HIV dogma to be overcome(14) in a paper published in this journal in 1993. We concur with this, certainly as far as the clinical aspect is concerned).

Here it becomes necessary to define our concepts and method.

Basic Concepts, Phenomenological Method
Human life can be described and defined in many ways, depending on our point of view.

An important basic phenomenon is clearly that of constant change (metabolism, development, transformation).

A person's current state of life (and health) is, therefore, a snapshot of a complex developmental process which may be said to have three basic aspects:

1 somatization (physical biography) determined from outside 2 socialization (social biography) shaped by self and others 3 intention (intentional biography) self-determined

The physical biography is determined by conditions "typical" for all human beings. Simplifying the matter we may speak of the human race being subject to natural laws which include the laws of development and aging, genetic aspects, laws governing the intake, transformation and elimination of matter. This part of our biography is predetermined; it is determined from outside.

At the other extreme we have our intentional biography. This depends on how we, as individuals, deal with our life. It is a self-determined act of freedom.

Between these two we live our social biography which is partly determined from outside (e.g. nationality and gender) but is also partly shaped and determined by ourselves; it lies between outside- and self-determination.

To avoid any misunderstanding let me say that these levels do, of course, initially form an indivisible whole that can only be differentiated in our thoughts. On closer consideration it also emerges that both in individual development - depending on the age reached - and in human evolution the balance between the three biographic aspects changes. This is clearly evident in childhood (the intentional aspect is little developed, the middle region is largely determined by the social environment; childhood diseases are, there- fore, highly "typical" and subject to strict laws).

Human development, human life, is thus unthinkable without the field of tension between outside- and self-determination. We may also call outside determination the "supra-individual" aspect (typical, subject to natural laws, generic). This part of the biography is largely determined, foreseeable and, within limits, "calculable". The opposite extreme, the individual, self- determined aspect of the human being is essentially creative, producing things that are new, and therefore unforeseeable and "incalculable". (Modern medical science is almost exclusively concerned with the calculable aspects of human reality. This makes it so convincing as a science, for questions and results relating to natural laws are usually repeatable).

The condition of "health" would thus be defined as: the individual's ability to maintain the balance between the supra-individual (typical) and individual (creative) aspects.

Conversely, the condition of "ill health" may be defined as: a shift in balance towards the supra-individual, typical (which may be due to external or internal natural laws). The more marked the shift, the more distinct (textbook-like) the disease.

The middle region, the social environment, can balance an upset equilibrium (a task for the art of healing, for instance) or increase it and, therefore, favor disease.

"Medicinal" in this sense would be measures that enable a person to maintain his individual nature, his intentions, in the face of the disease type.

Definitions should not block our view of the rich potential for variety in the world. They can only present a partial aspect of the complex disease phenomenon, an aspect, however, that would appear fruitful in the current context.

4. Therapeutic approach between self- and outside determination
If we consider AIDS in the light of the above, it can be seen to be a characteristic example of evolution from individual to typical aspects ("de-individualization") The disease begins in a variety of ways, being non-characteristic and individual and becomes increasingly more typical and instantly recognizable in its advanced stages. The approach to treatment results from the above characterization of the disease. On one hand the individual pole must be strengthened, and on the other the pole of external determination must be forced back.

It is, of course, easy to formulate such a hypothesis. It needs to be made specific for implementation. As a first step, let us consider certain aspects of external determination in some detail.

External determination of AIDS pathology
It is "typical" of AIDS pathology (pathology in the fullest sense) that affected individuals are subject to powerful external factors coming from two directions as soon as they are known to be HIV positive.

This is the (allegedly) inevitable progression from "positive HIV test" to AIDS and death, a route laid down - as the general message goes - by a life form infesting the blood and subject to mathematical, statistical laws of time and the pitiless dictates of laboratory parameters. The affected individual feels inwardly taken hold of by a "foreign will". This fills him with paralyzing fear and/or leads to evasion and repression strategies. Hopes for the future narrow down to foreign substances (the feverishly sought AIDS drug) and frequently suicide. Killing oneself thus becomes the ultimate symbol of free decision and self-determination. (Usually planned for a long time, suicide is often literally "celebrated" as driving the foreign element out of the body and taking one's revenge on the natural laws governing the body, laws not accessible to human intentionality).

The second factor is the "typical" reaction of others (including medical personnel), which tend to isolate the individual and determine the affected person's life from outside. Attitudes such as these arise from hysterical fear of an entity not perceptible to the senses that treacherously seeks to attack and destroy and only waits for an opportunity to invade. Defensive reactions are enhanced by a tendency to "typify" those affected (assignment to groups, moral judgment and condemnation). Absurdly enough this applies even to children, irrespective of the route of transmission.

The social environment often becomes unbearable for the patient, with the social biography entering into a vicious circle of fear, lies (a core problem in AIDS pathology) and withdrawal. Paralyzing fear of the changes subject to natural laws in one's own body, encounter with and lies from the social environment are undoubtedly powerful external factors.

The therapeutic triad: removal of fear, activation and change
The first step, usually only partly achievable yet all the more important, is to remove fear and free the individual from a narrow view of the future and the world. It creates the precondition for the steps that follow.

Basic conditions for the resolution of fear are an open, fearless approach and a social environment where people have awareness of the significance of truthfulness. This alone will remove the fear of medicine and its institutions and of unwanted diagnostic and therapeutic interventions. It provides the soil in which "broadening" of the patient's view of the world can grow. With new interest in the rich variety of the world, in nature, other people, and the social environment, the frozen inner attitude is resolved. A horizon previously reduced to an ominous virus, medicaments, symptoms and laboratory results can expand.

The preconditions are created for activation of such resources as are still extant. Avenues are opened up for something new and creative, elements that can be freely shaped in one's own destiny. Self-awareness and awareness of others, egotism and altruism can be brought into balance in a new way, which the individual finds for himself, and, finally, the social constriction also is resolved.

This is a process of change, with a disease tending towards constriction and destruction "changed" into its positive counter image. It is overcome as room is made for perception, insight and action, in spite, of, and indeed because of, the disease.

The finite nature of (one's own) life can be accepted as a universal law that has meaning and loses its will-paralyzing character. Limited periods of time are given their relative value and lose the aspect of hopelessness. Here and today, anything that can be done now becomes just as important as the future which, in the final instance, is limited for every human being. The utterly individual "melody of life" (what do I want to find in life, what meaning do I give to life) can be intuited and - in all modesty and with love for its imperfections - so that it begins to sing.

Change as an actual treatment goal means that the individual consciously addresses his development potential. Change and development, rather than standing still and paralysis, are the laws of life processes, and the process of change can take effect even at the level of physical functions.

Change is ultimately the ability to gain a new balance between natural laws at one extreme and intentionality at the other. The condition has been reached which was defined as "health" above, though in a sense it differs from the generally accepted. Here the concept of health becomes free from defined physical parameters (e.g. laboratory results). The latter become mere indicators that may point to the balance being threatened.

It is also possible to say to one's patient:

The disease does, of course, have aspects where it is subject to natural laws. This may be denned by reference to a virus, if one wishes, with figures and statistics used to define the type.

Human beings also have another aspect, however, which is individuality, intentionality and creativity. This determines the course the disease takes just as much as the laws of nature do. It is also possible to speak - to anyone prepared to listen - in terms of the field of tension between determination from outside and self-determination. This is the absolutely essential driving force for human development. Potential energies grow as the tension between the extremes increases. This is the tremendous challenge AIDS presents with its undoubtedly powerful aspect of outside determination. At the same time it is an enormous opportunity for development.

Importance of art therapies
Removal of fear, activation of inherent potential and change are processes that cannot happen unless great efforts are made to come to terms with oneself. Help and support will be needed from others (therapists). It will only rarely be possible to be consistent in following this path, for in many respects we lack the preconditions for this today. Yet - as our experience has shown - the therapist should not let this realization stop him from setting out on the path. Individual steps and partial results are also helpful.

Pharmaceutical substances should only be used for limited periods if possible, essentially as a prosthesis in crisis situations. Art therapies are the appropriate aids on the road to removal of fear, activation and change. They are material (modeling, painting) and immaterial (music, speech, poetry, eurythmy) "medicines" and serve to transmit a message from one person to another.

The therapist becomes the medicine, the quality of which depends entirely on his human and professional abilities (training - schooling).

Change as an extended form of rehabilitation
Change as the real treatment goal is undoubtedly related to rehabilitation, but we have chosen to use the term in an extended and specially-defined sense. It is not a question of "returning to the conditions that existed prior to the illness", as the term "rehabilitation" suggests. The "old conditions" did, after all, lead to the illness. The road which led to loss of balance must be abandoned and a new road found that leads to a new state of balance.

This is no doubt one of the most difficult messages in our approach to treatment, and many patients are unable to accept it or can accept only some of it. It (apparently) contradicts the strategies generally proposed today, where the goal is to maintain the usual life style for as long as possible. This, of course, is in reality quite impossible, for thoughts of the disease, symptoms, the need to take medicines, etc. change the individual's lifestyle quite considerably.

We must be careful not to impose our own views on the patient. They can only be presented when aspects such as these have become part of the patient's experience. It would go against the stated goal of strengthening the self-determination pole if a therapist sought to impose his own system and thus determine from outside.

5. Polarity at the Different Phenomenological Levels
Above, the polarity between supra-individual and individual aspects was said to be the driving force in human development. I would call this a polarity on the macro level. (This is even more so the case with the polarity between spirit and body). The question is: how far can the principle of polar forces also be seen at other phenomenological levels of life and utilized for therapeutic purposes?

It is easy to see polarity as the basic condition for life at the micro level when considering the membrane potential of cells, for instance. Here permanent loss of polar tension is identical with death. The theme of agonist and antagonist of messenger substances, which occurs in countless variations, also shows the polar principle. Medicine works on this level today when imbalances are corrected by substitution or inhibition.

Can the principle also be found at the meta level?

Functional polarity in the human body
Rudolf Steiner's researches led him to recognize two polar functional principles in the human organization as a whole: the neurosensory sphere on one hand, and the sphere of metabolism and limbs on the other.

Simplifying the issue, we may also speak of polarity between the upper and lower human being. (This is, of course, schematic and may cause misunderstanding, but initially it is helpful in thinking things through.) In the head, the upper human being, the neurosensory process is functionally dominant (not exclusively so); below the diaphragm, in the lower human being, metabolism determines function (though again not exclusively so). The fundamental differences are easily brought to mind if a phenomenological approach is used.

If we take this further, we realize that catabolism dominates in the upper, and anabolism in the lower human being. Processes dealing with imponderables (sensory impressions) are also mainly in the upper human being, those dealing with physical matter (digestion) in the lower.

This functional tension is balanced and mediated in the middle human being, in the rhythms of the pulsating blood and of respiration. Phenomenologically, seen in terms of the density and weight of matter, respiration is beyond the solid and fluid elements we have in digestion; yet, on the other hand, it is more material than our imponderable sensory impressions.

The middle position of the thorax can also be seen in the skeleton. Endoskeleton in the sphere of metabolism and limbs, exoskeleton in the region of the head, and in the thoracic region a rhythmic exoskeleton (the rib theme recurring and fading away) that gradually dissolves lower down.

Here we have a functional threefoldness of the organism, with the tension between extremes the driving force.

Thinking in analogies - a useful method?
The above may be seen as a pretty analogy and accepted or rejected as such. Yet what matters is whether this approach can be used to develop useful ideas for treatment.

If we consider HIV infection from this point of view, we realize that its primary manifestation is in all three functional spheres.

If the question as to where AIDS-defining pathology finds its location is seen not as chance exposure to a pathogen (i.e. statistical risk relative to CD4 cell count), but functional dispositions are also taken into account, our treatment strategies will differ from those generally used.

It then becomes justifiable to ask why one person first develops pneumonia (middle human being), for instance, another severe diarrhea (lower human being) and a third an opportunistic infection of the central nervous system (upper human being), and why in an individual case the pneumonia is followed by diarrhea or toxoplasmic encephalitis. Is this chance or can an inner (polar) connection be found between these events?

We noted that tendencies to diarrhea and severe cerebral manifestations are interrelated in that people with cerebral disease do not usually develop diarrhea and, in fact, are not infrequently suffering from persistent constipation.

Alternation in time is another feature. Recently, we had a patient with severe nonspecific diarrhea who would develop focal seizures as soon as his diarrhea stopped. The hypothesis we have evolved from this is that the above manifestations show alternation between the opposite poles in the human being that were discussed above. We are, therefore, always on the lookout for early neurological signs in patients with persistent constipation and will take preventive action where indicated, using (saline!) laxatives. It will require further investigation to see if this measure will actually reduce the frequency and severity of cerebral events.

Symptoms - indications of counter-regulatory reactions?
This raises questions which may be of considerable clinical import:

Can symptoms in one functional sphere of the organism be signs of counter-regulatory reactions at the other extreme? Also, could it be that exhibition of prophylactic antibiological agents (currently the major strategy to prevent opportunistic infections) favors manifestations of a different kind in another site?

Figures for the evolution of opportunistic infections over the last 6 years published by the German Federal Department of Health(15) would, in my opinion, fit in with the hypothesis. Thus the incidence of Pneumocystis carinii pneumonia (PCP) showed a distinct reduction (by almost 20%) with preventive treatment (mainly pentamidine), but the incidence of opportunistic infections has been rising steadily (from 67% in 1987 to 72.4% between 7/1993 and 6/1994). The main infections have been toxoplasmosis, which is more difficult to treat, CMV infection with its wide range of manifestations, and typical and atypical mycobacterial infections.

I am familiar with the objections which are raised: the last-named opportunistic infections only manifest with low CD4 cell counts (less than 50- 100 /ul). From this point of view, it is due to PCP prophylaxis that more of those affected experience the more advanced stages of the disease. In my view, these are important considerations but not proof for they base merely on surrogate markers such as the CD4 cell count.

Multiple prophylaxis used to treat statistical risks
It would go too far at this point to discuss all the pros and cons of relatively broad-spectrum antibiotic prophylaxis to prevent opportunistic infections with HIV syndrome.

At the least, statistically demonstrable reduction in infection should not, in itself, be considered adequate justification for the widespread use of powerful drugs with numerous potential side effects. The likelihood of resistance developing, the negative effect of exposure to resistant pathogens and substances with uncertain long-term toxicology, both on the individual and on subsequent patients, must be taken into account just as much as the possible extension and quality of life.

It seems to me it would be more intelligent for anyone who feels it necessary to pursue such a strategy to use specific prevention or perhaps treatment, establishing a risk profile for the individual patient. Points of view such as those given above concerning the threefold organization of the human being may prove helpful in this and should be explored.

It also seems to me that qualitative aspects are left aside in the discussion of broad-based prevention (5-fold prophylaxis is not uncommon today). To mention just one: can a primary manifestation such as pneumonia have positive effects at another level of the human defense system?

On several occasions we have seen patients who had overcome PCP (So far no PCP with fatal outcome at our hospital.) gain a different attitude to their disease and, hence, an opportunity to use their resources.

After the pneumonia I actually realized that I have to be active myself and started to make something of the time which is available to me. I started to live.

This is an important basic issue in the treatment of AIDS. Our present view is: instead of a schematic strategy dependent on numerical values the atm is to develop an individual risk profile for each patient which covers physical aspects (weak points, prior problems, dispositions) as much as intentional potential (active prevention, e.g. with art therapies), the social network (social support) and psychological conditions (fear and anxiety, repression).

Much research clearly still has to be done; the benefit of such research would, however, greatly outweigh the cost if positive results could be achieved. An additional gain would be made not only in quality of life for the patient but also in reduced financial expenditure, doubtless with greater need for human resources. Our clinical experience to date would seem to bear this out.

6. Schematic Review of Treatment Strategies
1 Considering the human being in terms of processes in polar fields of tension at three levels:

Biographic (mega level) Organismal and functional (meta level) Fine material, cellular (micro level)

2 Therapeutic steps at the mega and meta levels

Art therapies, biography work and process-activating medical treatment

Removal of fear

Personal activation

Change

3 Intervention on micro level if balance can no longer be maintained ("pros- thetic function")

Supporting material and processual balances with substances and medicaments

Suppressing foreign processes (e.g. antibiotics, virostatics, antimycotics).


Christof Schnuerer, MD
Geineinschaftskrankenhaus Herdecke
Beckweg 4
D-58313 Herdecke
Germany

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