WHAT IS MOLLUSCUM? HOW DOES MOLLUSCUM SPREAD? HOW DO I KNOW IF I HAVE MOLLUSCUM? HOW IS MOLLUSCUM TREATED? CAN MOLLUSCUM BE PREVENTED? DRUG INTERACTION PROBLEMS THE BOTTOM LINE WHAT IS MOLLUSCUM? Molluscum contagiosum is a skin infection. It is caused by a virus. Molluscum causes small bumps (lesions) to appear on the skin. Most of them are less than half an inch in diameter. They have a hard white core. Some lesions have a small dent or dimple in the center. The lesions are the same color as normal skin, but they look waxy. They usually don’t hurt or itch. The molluscum virus is very common, and almost everyone has it in his or her body. A healthy immune system will control molluscum so that if lesions appear, they do not last a long time. People with weakened immune systems can develop molluscum lesions that spread, last a long time, and are very difficult to treat. About 20% of people with AIDS will develop molluscum. Molluscum is not a serious health problem. However, many people find the molluscum lesions to be very unattractive. This can cause serious emotional or psychological problems. HOW DOES MOLLUSCUM SPREAD? Molluscum can be spread by direct skin contact. It often spreads through sexual activity. Molluscum can infect any part of the skin, but it is especially common on the face or in the groin and pubic areas. It can be spread from existing lesions to other parts of the body or to other people. It can also be spread by objects (or clothing) that came in contact with a lesion. Men with HIV often develop molluscum on their face. Shaving with a razor blade can spread it. HOW DO I KNOW IF I HAVE MOLLUSCUM? A health care provider can easily identify molluscum lesions. They are waxy, flesh-colored bumps that don’t hurt or itch. There are only one or two other infections that cause skin problems that look at all similar to molluscum. HOW IS MOLLUSCUM TREATED? Molluscum lesions are treated the same way as warts. Unfortunately, the lesions often return and need to be treated again. They can be frozen with liquid nitrogen. This is the most common method of treatment. They can be burned with an electric needle (electrocautery) or a laser. This treatment can be painful and sometimes leaves scars. They can be treated with chemicals used on warts such as trichloroacetic acid (TCA), podophyllin or podofilox. These chemicals can not be used on sensitive skin or near the eyes. They can be cut or "scooped" out surgically. This treatment can be painful and can leave scars. They can be treated with drugs used to treat acne such as tretinoin (Retin-A) or isotretinoin (Accutane). This is a newer approach. These drugs reduce the amount of oil in the skin. The top layer of skin dries out and peels off. These drugs can cause redness and soreness. Retin-A is a cream that is put onto the lesions. Accutane is taken in pill form. Another new approach is to use the antiviral medications cidofovir or imiquimod. These drugs are applied directly onto the lesions. They can cause local skin irritation. CAN MOLLUSCUM BE PREVENTED? Because the virus that causes molluscum is so common, it is not possible to avoid being exposed to it. However, if you have molluscum you should make sure that the lesions don’t touch anyone else. You should also be careful not to spread molluscum to different parts of your body. Be careful not to scratch the lesions or to cut them while shaving. Some health care providers think that using an electric shaver helps prevent the spread of molluscum. DRUG INTERACTION PROBLEMS The acne drugs tretinoin (Retin-A) and isotretinoin (Accutane) tend to dry out the skin. Dry skin is also a side effect of the protease inhibitor indinavir (Crixivan) and some other antiretroviral medications (ARVs). If you take use Retin-A or Accutane to treat molluscum along with ARVs that can cause dry skin, your skin problems could get worse. THE BOTTOM LINE Molluscum is a viral infection that can produce skin lesions. Although they are not medically dangerous, the lesions can cause serious emotional and psychological problems. Molluscum can be spread from person to person by direct skin contact. It can be spread during sexual activity. If you have molluscum, you can spread the lesions to new areas if you shave with a blade. Molluscum lesions are removed in the same ways as warts. Unfortunately, they often return and have to be treated again. source: The AIDS Infonet

This background article addresses two different audiences. It is both an introduction for persons not familiar with AIDS and the HIV exclusion issue, and also a resource for activists; it includes information not generally available or not published before. Chronology * The U. S. Public Health Service (PHS) has long maintained a list of “dangerous and contagious diseases,” mostly sexually- transmitted diseases, for excluding persons for public-health reasons from the United States. This list is widely regarded as obsolete by health experts. * In June 1987 the PHS, under pressure from President Reagan, added AIDS to the list, but noted that the exclusion was not based on any new scientific knowledge and that “AIDS is not spread by casual contact which is the usual public concept of contagious.” * In July 1987 the “Helms amendment” by Senator Jesse Helms (Republican, North Carolina) added HIV infection to the exclusion list. Because AIDS was already on the list, Congress thought the change was not important, and through a political compromise the amendment was passed unanimously in the Senate. Later, however, it would be argued that since Congress had put HIV on the list, only Congress could take it off — although in regard to all other diseases, the list was maintained by the PHS. * In April 1989 Dutch AIDS educator Hans Paul Verhoef, on his way to an AIDS conference in San Francisco, was detained in Minneapolis by the U. S. Immigration and Naturalization Service (INS), an arm of the Department of Justice, when AZT was found in his luggage. Through legal action by the conference organizers, a waiver was obtained, but only when the conference was ending. The AIDS community then realized that the June 1990 Sixth International Conference on AIDS in San Francisco, the major scientific meeting on AIDS in the year, could be disrupted because persons with HIV would be unable to travel to San Francisco to attend. A year’s effort by the Conference organizers and the AIDS community failed to end the ban; various waiver rules were devised, but there were problems with them. Because of the travel ban, over 70 AIDS, medical, and government organizations, including the International Red Cross, the British Medical Association, and the European Parliament, boycotted the meeting. Although the Conference organizers sent waiver instructions to potential delegates and organized legal panels in case of problems at the border, it is likely that thousands of people stayed away; thousands of others demonstrated at the San Francisco meeting. As a result of this experience, Harvard University, which had been selected to organize the May 1992 Eighth International Conference on AIDS in Boston, announced that it would withdraw its sponsorship unless persons with HIV were able to travel freely to attend. * In March 1990 public-health experts at the U. S. Centers for Disease Control recommended that all diseases except active tuberculosis be removed from the list of excludable conditions; HIV was left on the proposed list because it had been put on by Congress. The Public Health Service never acted on this proposal. * In November 1990 the Immigration Reform Act of 1990 was signed. It directed the CDC to establish a new list of excludable conditions, based solely on “current epidemiological principles and medical standards,” by June 1, 1991. * On January 23, 1991, the CDC published in the Federal Register its proposal that only active tuberculosis remain on the list of excludable conditions. (Other provisions of the law allow exclusion of persons with a dangerous mental disorder, one who abuses drugs, or one likely to become a “public charge,” i.e., to require government assistance. These sections have not been involved in the HIV controversy, however.) * During a 30-day public comment period on this proposed rule, right-wing religious leaders generated 35,000 postcards and letters opposed to removing the HIV exclusion. And in Congress a letter from the Republican Study Committee, circulated by Representative William E. Dannemeyer (Republican, California) and signed by 67 members of the House of Representatives, opposed removing the ban. Opponents focused their arguments on immigration, not on travel, although for technical legal reasons it will be difficult to separate the two without new legislation, meaning that if the list proposed by the PHS (excluding only active tuberculosis) is not accepted, the travel ban will also continue. * About a week before the June 1 deadline, a major dispute surfaced between the U. S. Department of Health and Human Services (HHS) and the U. S. Department of Justice; the latter opposed removing HIV from the list. Until shortly before that time, no one in the AIDS community had known that the Department of Justice was involved in the issue; the law clearly gives sole authority to establish this list to HHS. But politically, although the two departments have theoretically equal Cabinet rank, Justice is closer to the White House, and therefore likely to win a dispute; in addition, the 35,000 letters opposed, and the letter from 67 members of Congress, gave it additional advantage. * Because of this conflict between Federal departments, an interim rule was put into effect last Saturday, June 1, and a new public comment period was extended for 60 days. The interim rule keeps the current exclusion list, including tuberculosis, HIV, and a number of other diseases, and keeps the waiver provisions negotiated in advance of the June 1990 International Conference on AIDS in San Francisco. However, this “interim” rule will not expire after the 60 days. It will remain indefinitely until replaced by another rule. Without an outpouring of public support for removing HIV from the list, the PHS will be reluctant to implement the decision — even one unanimously supported by medical and public-health experts. The current policy will continue — including the travel ban, which will affect the May 1992 International Conference on AIDS in Boston. Also continuing will be the deportation of HIV-positive applicants under the immigration Amnesty program, who have lived in the United States for at least nine years

WHAT IS HPV? HOW CAN HPV BE DETECTED? CAN HPV INFECTION BE PREVENTED? HOW ARE HPV INFECTIONS TREATED? THE BOTTOM LINE NOTE: In the US, counseling and referrals are available on a national human papillomavirus (HPV) hotline. Call toll-free at 877- HPV-5868 (877-478-5868.) WHAT IS HPV? There are over 100 viruses known as human papilloma virus (HPV.) They are common. One study found HPV in 77% of HIV-positive women. HPV is transmitted easily during sexual activity. It is estimated that 75% of all sexually active people between ages 15 and 49 get at least one type of HPV infection. Some types of HPV cause common warts of the hands or feet. Infections of the hands and feet are usually not transmitted through sexual activity. Several types of HPV cause genital warts on the penis, vagina, and rectum. Those with HIV can get worse sores in the rectum and cervical areas. HPV can also cause problems in the mouth or on the tongue or lips. Other types of HPV can cause abnormal cell growth known as dysplasia. Dysplasia can develop into anal cancer in men and women, or cervical cancer, or cancer of the penis. Dysplasia around the anus is called anal intraepithelial neoplasia (AIN). Anal intraepithelial neoplasia is the development of new abnormal cells in the lining of the anus. Dysplasia in the cervical region is called cervical intraepithelial neoplasia (CIN). AIN or CIN appear to be more common in people with HIV infection than those who are HIV negative. HOW CAN HPV BE DETECTED? To detect HPV, health care providers look first for the problems HPVs cause: dysplasia or genital warts. Dysplasia can be detected by Pap smears. They are usually used to check a woman’s cervix. They can also be used to check the anus in men and women. A swab is rubbed on the area being checked to pick up some cells. They are smeared on a glass slide and examined under a microscope. Reflex HPV testing is used to follow up on Pap smear results that are not clear. It can indicate who needs more careful examination or treatment. The reflex test identifies which types of HPV are present and can indicate if aggressive treatment is needed. Some researchers believe that anal and cervical smears should be checked each year for people with elevated risk: People who have had receptive anal intercourse Women who have had cervical intraepithelial neoplasia (CIN) Anyone with under 500 CD4 cells. However, other researchers think that careful physical examination can detect as many cases of anal cancer as anal Pap testing. Genital warts can appear anywhere from a few weeks to a few months after you are exposed to HPV. The warts might look like small bumps. Sometimes they are fleshy and look like small cauliflowers. They can get bigger over time. Your health care provider can usually tell if you have genital warts by looking at them. Sometimes a tool called an anoscope is used to look at the anal area. If necessary, a sample of the suspected wart will be cut off and examined under a microscope. This is called a biopsy. Genital warts are not caused by the same HPV that causes cancer. However, if you have warts, you may have also been exposed to other types of HPV that could cause cancer. CAN HPV INFECTION BE PREVENTED? There is no easy way to tell if someone is infected with an HPV. People who don’t have any signs or symptoms of HPV infection can transmit the infection. Condoms do not totally prevent transmission of HPVs. HPVs can be transmitted by direct contact with infected areas that aren?t covered by a condom. Men and women with HIV who are sexually active may want to have a regular Pap smear, anal and/or vaginal, to check for abnormal cells or early signs of warts. A positive result can be followed up to see if treatment is needed. A vaccine called Gardasil was approved in 2006. However, it has not been tested in or approved for people already infected with HPV. HOW ARE HPV INFECTIONS TREATED? There is no direct treatment for HPV infection. Some people “clear” an HPV infection (are “cured”). They can later be infected with HPV again. However, dysplasias and warts can be removed. There are several ways to do this: Burning them with an electric needle (electrocautery) or a laser Freezing them with liquid nitrogen Cutting them out Treating them with chemicals Other, less common treatments for warts include the drugs 5-FU (5-fluorouracil) and Interferon-alpha. A new drug, imiquimod (Aldara®), has been approved for treatment of genital warts. Cidofovir (Vistide®), originally developed to fight cytomegalovirus (CMV), might also help fight HPV. HPV infection can last for a long time, especially in people who are HIV-positive. Dysplasia and warts can return. They should be treated as soon as they are found to reduce the chances of the problem spreading or returning. THE BOTTOM LINE Human papilloma viruses (HPV) are fairly common. Different types of HPV cause warts or abnormal cell growth (dysplasia) in or near the anus or cervix. This abnormal cell growth can result in cervical or anal cancer. Genital HPV infections are transmitted through sexual activity. HPV infection can last a long time, especially in people with HIV. A Pap smear can detect abnormal cell growth in the cervix. It can also be used to check the anus of men and women. Although Pap smears may be the best way to detect early cervical cancer, careful physical examination may be the best way to detect anal cancers. The signs of HPV infection – warts or dysplasia – should be treated as soon as they show up. Otherwise, the problem could spread and be more likely to return after treatment. For more information, see the web site https://www.thehpvtest.com/ source: The AIDS Infonet

A series of laboratory tests at the Linus Pauling Institute of Science and Medicine in Palo Alto, California found that ascorbate (vitamin C) reduced the growth of HIV in cultured human lymphocytes, in concentrations not harmful to the cells. The experimental study, conducted by Steve Harakeh, Ph.D., and Raxit J. Jariwalla, Ph.D., appears in the September issue of the Proceedings of the National Academy of Sciences, USA; results were also presented September 11 at “Ascorbic Acid: Biological Functions and Relation to Cancer,” an international symposium sponsored by the U.S. National Cancer Institute, and National Institute of Diabetes and Digestive and Kidney Diseases, in Bethesda, Maryland. The study is extensive and hard to summarize, but it showed a substantial reduction in measures of viral activity (p24, reverse transcriptase, and syncytia formation) without toxicity to cells at concentrations of 25 to 150 mcg/ml, with the higher concentrations working better. How much vitamin C would be needed to reach these levels in blood serum? This study did not measure blood levels, but the published paper cited measurements by others. One researcher found an average blood level of 28.91 mcg/ml after oral use of 10 grams of vitamin C. Another found that intravenous infusion of 50 grams a day led to a peak plasma level of 796 mcg/ml. Comment This research appears to have been carefully done; many measurements were made and the results all point in the same direction. We raised several questions, however, and gave Dr. Jariwalla a chance to respond. One potential limitation is that this study used cultured cells and viruses, which have been bred in laboratories; recently scientists have learned that viruses and cells freshly obtained from patients can give different, and presumably more reliable, results in drug screening. In our interview, Dr. Jariwalla noted that at this time there is no evidence that strains differ in resistance to ascorbate — but that different strains have not yet been tested. One question about the usefulness of vitamin C concerns the relatively narrow range between effective and toxic doses found in this study. Effectiveness began to be seen at 25 mcg/ml, but toxicity was found at 400 and above; half or more of the cells were killed by exposure to 400 mcg/ml or greater for four days. The therapeutic range is therefore fairly narrow; for some drugs, the corresponding ratio between effective and toxic doses is a thousand or more, compared to 16 (400 divided by 25) in this laboratory test of vitamin C. Dr. Jariwalla said that “although this may be so, there is no evidence of ascorbate toxicity found in human beings when large doses have been taken. The only side effect of high doses of ascorbate is a mild laxative effect. There are no reliable reports of severe ascorbate toxicity, such as acidosis or kidney stones.” Several years ago there was much interest in high-dose vitamin C as an AIDS treatment. By the end of 1987 this interest had greatly diminished, although some people continue to use the treatment today. One reason we have been skeptical of vitamin C is that if the treatment had worked well, it seems unlikely that the community would have stopped using it. Dr. Jariwalla said that interest in vitamin C as a potential AIDS treatment had diminished for several reasons. fFirst, the emphasis shifted to AZT and other nucleoside analogs as antivirals. Second, no clinical trials of vitamin C and AIDS got off the ground. And third, no hard scientific evidence of the effect of ascorbate on the AIDS virus was available until now. At least two clinical trials were proposed years ago by leading AIDS researchers, but no funding was available. The Linus Pauling Institute, which has long been interested in vitamin C, has heard “a number of reports…from AIDS patients who had taken high doses of vitamin C and had experienced a marked improvement in their condition” (quote from a press release accompanying the recently published article). It is possible that results today could be better than those of several years ago, when treatment was only used late in the illness. Today, treatments are started earlier; and AZT and others antivirals make possible combination therapies, which were not available during the time of great interest in vitamin C. The article suggests a rationale for such combinations. We asked Dr. Jariwalla what the study suggested about an appropriate dose of vitamin C. He said other results indicate that at least 10 grams orally would be needed to obtain the minimum blood levels for antiviral effect. Higher doses can be obtained through intravenous infusion, to reach plasma levels in the range found most effective in the laboratory tests. He cautioned, however, that further clinical studies are required to establish the optimum method of administration for maintaining high levels of ascorbate in the blood. Note: large doses of vitamin C are usually taken as a powder, not as pills. We asked about the different forms of the vitamin which are available. The Linus Pauling Institute sent us an information sheet which said that “Vitamin C, from Bronson Pharmaceuticals, La Canada, California, is available in the form of ascorbic acid, sodium ascorbate, calcium ascorbate, or sodium ascorbate and ascorbic acid combination.” The sodium or calcium ascorbate salts are used to reduce slight acidity in the urine due to ascorbic acid. Dr. Jariwalla said that for oral use of high doses, the mixture of sodium ascorbate and ascorbic acid should be used — or calcium ascorbate for persons on a sodium-restricted diet. We suggest that patients discuss vitamin C, or any treatment they are considering, with their physician. A nutritionist told us that some patients have sought treatment for diarrhea, not realizing that it was caused by taking too much vitamin C; until they told their physician that they were using the vitamin, the actual cause of the diarrhea was not suspected. Persons should also realize that suddenly stopping high doses of vitamin C can cause deficiency symptoms, as the body is used