Object: The S⁶⁹-X-X (X indicates one amino acid) insertion, conferring drug-resistance to multiple nucleoside reverse transcriptase (RT) inhibitors, has been identified in the RT of human immunodeficiency virus type 1 (HIV-1). We now report 4 kinds of insertion mutations which were identified in viruses isolated from 3 HIV-1 infected patients.
Patients and Methods: Fifteen HIV-1 infected hemophiliacs who receive d RT inhibitors for more than 3 years were examined. HIV-1 RNA was extracted from the plasma virus, and the RT regions were sequenced.
Results: The S⁶⁹-X -X insertion mutations were found in 3 out of 15 patients. These mutations emerged under conditions where the patients were receiving ZDV+3TC, ddI+d4T or ZDV+ddI. In one case, the pattern of insertion changed from S⁶⁹-S-S to S⁶⁹-S-G during ZDV+ddI treatment. After insertion mutations were detected, treatment of these three cases was switched to one protease inhibitor plus two RT inhibitors combination therapies, and their HIV-1 RNA levels decreased to below the detection limit. In two patients, the HIV-1 RNA levels were maintained below the detection limit for more than one year after the protease inhibitors were added in the course of treatment. In the other patient, no pattern indicative of the insertion was found in the HIV-1 RNA appearing at the time of relapse.
Conclusion: The results revealed that the insertion mutations were not particularly harmful from the clinical point of view. To determine the influence of these insertions on the clinical course, further investigation is needed.

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Objective: A system for patients living with HIV/AIDS (PLWHA) to receive quality treatment is being established, and regional differences in the quality of the care for Japanese PLWHA have narrowed. But because no special governmental policies are in place for foreign PLWHA living in Japan, they face many unresolved problems . In order to resolve the problems, we examined the situation of foreign PLWHA residing in Japan.
Methods: We distributed a preliminary questionnaire to 364 area h o spitals specializing in AIDS treatment, followed by a more detailed questionnaire to the 117 hospitals which treated foreign PLWHA in the last 5 years.
Results: Foreign PLWHA mainly reside in Kanto-Koshinetsu, Tokai and Kinki. The greatest number of PLWHA treated in hospitals in the last 5 years are Thai speakers, followed by Portuguese and English speakers. About 31% of the Thai, 42% of the English and 50% of the Portuguese speakers continued their treatment at the same hospital. However, about 38% of the Thai, 34% of the English and 25% of the Portuguese speakers went back to their country. 71% of the Thai speakers did not have health insurance. In contrast, only 18% of the Portuguese speakers lacked coverage. In the case of PLWHA without health insurance, a commonly reported problem was unsettled fees. An other major problem was the difficulty of communication in languages other than English.Discussion: To improve the effectiveness of medical services available to foreigners in Japan, we must consider the differences in the economic situation, health insurance coverage and cultural attitudes of each language group. Also to improve the quality of HIV/AIDS treatment, specialized medical interpreters are required.

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Case: A 22-year-old Japanese male with hemophilia B and AIDS was described. His clinical course had been complicated by recurrent herpes zoster and oral candidiasis. Poor adherence to former antiretroviral therapy might have been associated with the multi-drug resistance in genotypic analysis. After starting a regimen consisting of stavudine, lamivudine, saquinavir, and nelfinavir, substantial improvements both in CD4+ cell counts and clinical status were seen despite his plasma viral load consistently showing titers above 4.0log₁₀ copies/ml.
Discussion: A number of patients who initiate highly active antiretroviral therapy eventually experience virologic failure. Medication for such patients has been switched based on the viral load, a surrogate marker for clinical progression of HIV infection. However, these patients have few therapeutic options. What constitutes failure of antiretroviral therapy is still controversial. It may be premature for clinicians to change antiretroviral therapy solely on the finding of detectable viral loads.

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