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 masterís 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, VVAís
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 nationís 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
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
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, isnít 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
bodyís 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 havenít 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 donít 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
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
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. Thatís when someone
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
VVA: Is it possible that an HIV-positive person never gets
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 doesnít 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 personís 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
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.
Itís 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 donít have HIV. We also are trying to find out what happens
with the HIV, to see if that goes any faster or not. We donít 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 VAís 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
VVA: Are there new medications being tested for treatment of
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 donít
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
donít 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 donít 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
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 donít 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.