Surviving and Thriving with AIDS: Hints for the Newly Diagnosed Michael Callen, Editor

©1987 PWAC NOTE: THIS IS OLD NEWS, posted for historical research only. The medical information herein is extremely outdated!

TREATING OPPORTUNISTIC INFECTIONS AND AIDS ITSELF


PREVENTING PCP (PNEUMOCYSTIS PNEUMONIA):
SOME THOUGHTS ABOUT PROPHYLAXIS
by Michael Callen

Although I have had several "non-specific pneumonias" since I was first diagnosed with cryptosporidiosis and AIDS in the summer of 1982, so far as I and my doctor know, I have not had pneumocystis pneumonia (PCP). (My initial experience being bronchoscoped was so horrible and traumatic that I have sworn never to permit it again. Some people don't mind being bronched; I hated it.)

I and Dr. Joseph Sonnabend, my physician, believe that the reason I've managed to avoid getting PCP is that almost from the beginning I have taken prophylactic medications to prevent PCP. As most of you know, PCP is the number one cause of death for PWAs. Therefore, anything which has a good chance of preventing its occurrence or recurrence seems like a pretty good idea to me.

I have spoken with many other PWAs who are on prophylaxis. I have also spoken to many medical authorities about the pros and cons. And I have spoken to PWAs who for whatever reason have chosen not to take prophylactic medications to prevent PCP. Though I am not, of course, a doctor, I want to recommend in the strongest possible terms that PWAs seriously consider prophylaxis.

Before I share with you the specific results of my survey of other PWAs and physicians, I must reiterate that I and this publication are not in a position to recommend treatments. The crucial decision of whether and what medications to take is yours to make in consultation with appropriate medical personnel. But I urge you to raise the issue of prophylaxis with your doctor(s) and to get a second or third opinion if your primary care physician is against prophylaxis.

Also, I need to reiterate that some of the drugs used to prevent and treat PCP can have serious side effects. Before you take any medication, familiarize yourself with the side effects and be on the look-out for the first sign of an adverse drug reaction. You should urge your physician to regularly monitor blood indicators of the side effects of certain drugs listed below.

One of the physicians I spoke with believes nobody should get pneumocystis pneumonia a second time. There are a variety of medicines which will substantially reduce the probability that PCP will recur. While to my knowledge, there have been no completed and published reports that definitively prove the efficacy of any treatment to prevent PCP in PWAs, observations indicate that a number of treatments are very likely to be effective in this respect.

Treatments that may be useful in PCP prophylaxis include:

1. Dapsone. A daily dosage of 100 mg. (25 mgs. four times a day) has been administered for PCP prophylaxis by many physicians since about 1983. It is probably quite effective. There are some side effects, the most frequent of which is anemia. However, with appropriate monitoring, this rarely poses a significant problem. Dapsone contains sulfur and some people are allergic to it.

2. Bactrim or Septra. Published studies in pediatric non-AIDS patients at risk for PCP have shown that this drug can effectively prevent it. One double strength tablet twice a day probably has considerable efficacy in preventing PCP in adults with AIDS. There are side effects with this drug, including a lowered white blood count. It is also a sulfur-containing drug and allergic reactions are not uncommon. However, individuals who are allergic to Bactrim have frequently been able to take dapsone.

3. Fansidar. This drug is also a sulfur-containing preparation. It is administered once a week by mouth and probably has a high degree of efficacy. Allergic reactions may develop and because the drug remains in the body for a week, these allergic reactions may be difficult to control. Many physicians have administered Fansidar with good results.

4. Aerosol Pentamidine. Trials of aerosol pentamadine are being conducted with the administration of Pentamidine by aerosol weekly or bi-weekly to prevent PCP. The optimal dosage and frequency of administration have yet to be established. This mode of prevention appears to be the most benign and may well become the preferred mode of PCP prophylaxis. It was pioneered by the Infectious Disease Service at Memorial Sloan-Kettering Cancer Center where the optimal conditions of administration are now being worked out.

A Word About AZT:

Anecdotal reports indicate that AZT does not appear to prevent pneumocystis pneumonia, although it has been claimed that AZT delays its onset. Fortunately, the AZT protocol has recently been changed to permit the concurrent use of Bactrim for PCP prophylaxis. (See #2 above.) Of course, as I stated elsewhere, the issue of PCP prevention should have been addressed in the original study design and it is to be hoped that in future studies, no one will be left unprotected from a recurrence of PCP. Many PWAs have faced the difficult choice of giving up their Bactrim prophylaxis which many physicians believe almost definitely prevents PCP in order to receive an experimental and toxic treatment whose beneficial effects cannot yet be known. PWAs should never have been placed in such a dilemma.

Aerosol pentamidine is probably acceptable with regard to the AZT protocol regulations and Dapsone should also be considered by those responsible for the protocol.

Overview of Objections to Prophylaxis:

The most common objection to the use of PCP prophylaxis has been that there is no established protocol. However, anyone with AIDS who has had PCP has a realistic probability of experiencing a second episode. It seems unconscionable to wait for the unequivocal demonstration that a particular prophylactic method will guarantee freedom from recurrence. Considering the gravity of PCP, it should be sufficient that a therapy has a very good chance of effectively preventing a recurrence. Of course, studies on the efficacy of the agents mentioned above must continue. However, even without the final results of such studies, I believe prophylaxis should be offered.

Many physicians in New York City have been administering PCP prophylaxis for some years with good results. However, there are physicians in New York City whose practice is not to administer such prophylaxis, and if this is true in New York City, it is likely that many more patients go without prophylaxis in smaller communities.

Physicians tend to respond to authoritative recommendations regarding the management of specific diseases. For example, the Public Health Service would represent such an authoritative voice. While no such recommendations are likely to be made in the absence of clear-cut data, suggestions may certainly be given while such data is being collected. I would urge all readers, in particular PWAs and physicians managing the treatment of PWAs, to contact the CDC and the Public Health Service. Encourage them to immediately begin formulating interim guidelines for prophylaxis against PCP.

PCP Prophylaxis in People with AIDS-Related Conditions:

While individuals who have had one episode of PCP would benefit from prophylaxis, People with AIDS-Related Conditions and People with AIDS who have not yet had PCP could also usefully receive PCP prophylaxis. However, precisely what criteria to determine whether a particular individual should receive PCP prophylaxis remain to be established. Studies designed to elucidate the factors predictive of the development of PCP are urgently needed.

If the modality used for prophylaxis is not significantly toxic, as may be the case for aerosol pentamidine, then the selection of patients to prophylax can be broader, as the potential benefit would clearly outweigh any possible harm. We urge you to discuss the issue of PCP prophylaxis with your physician.

KAPOSI'S SARCOMA AND CHEMOTHERAPY
by Ken Meeks

The first KS lesion appeared on my biceps in April/May 1984. I figured it was a scratch, a bruise, whatever, and that it would soon go away. It didn't. I went through 10 months of denial as the lesions continued to appear. The physician confirmed KS on Valentine's Day, 1985. I had my first visit with the oncologist (your cancer specialist and your best friend in this) in March. In April he suggested chemotherapy.

It's important to remember that KS, unless significantly advanced and/or especially aggressive, is not a life-threatening illness. You don't have to make decisions today in order to survive, and I heartily recommend Nancy Burning's book on coping with chemotherapy.

So, on April 8, 1985, I began one week a month of in-patient chemotherapy. I figured this nonsense had gone on long enough without treatment. The drug chosen was Vincristine dripped through an intravenous tube 24 hours a day in a very dilute solution under pressure. That's why the in-patient status.

All chemotherapy medications are toxic, but their toxicity is focused on the cancer cells to destroy them or destroy their ability to reproduce. Vincristine has a tendency to be neurotoxic: nerve cells in the hands and feet are generally affected first. You must let the oncologist know this because irreversible damage can take place. You'll think your arms, hands, and legs and feet are "asleep" all day. Vincristine also affects the intestinal nerves and can thereby cause constipation--generally easily taken care of with Colace or another stool softener. I experienced no other side effects.

But by August, it became apparent that we had reached something of a plateau and the Vincristine no longer seemed to be doing the job it had done earlier. Switch!

New studies now indicated that Vinblastine (Velban) was the drug of choice. A new experience. I go in once a week, have my blood tested, see the oncologist, and if all's well, get a small shot, again IV, and go home. As with anything that you're throwing into your body that's toxic, the Velban takes its toll. I frequently spend Friday afternoons, after my morning treatment, napping and sometimes I spend the whole weekend dragging. The major side effect of concern is my white cell count: Velban attacks the white cell production in the bone marrow. I'm already immune deficient, so we don't want to compound it by heavy doses of chemo. My oncologists allows me 25% deviation below normal; if my white cells are too low, there's no chemotherapy.

The choice of medication and mode of application is something to be discussed between you and your oncologist. You've read about my experiences and should gather I've been quite pleased. Remember, however, that there are other cancerous diseases PWAs may fall prey to, and therefore a different course of treatment may be recommended. Remember, too, that each person is different and what works for one may not be right for another. Ask questions and find out what the devil is going on. Read voraciously!

Now, what happens if the side effects are worse than mine? Nausea can frequently be controlled by anti-nausea medication, including a recently approved extract-of-marijuana pill; and some people smoke grass. Hair loss cannot be stopped (and don't use a tight-fitting ice cap to keep the chemo from your hair--it'll also keep the chemo from lesions on your scalp!). But if a short haircut won't help you, your oncologist can write a prescription for a therapeutic hair replacement (wig, rug, toupee) which may be covered by your insurance plan. And remember: bald can be beautiful!

Hang in there. You're not the first. Some of us have been around four and five years. And if your physician has told you you'll be dead in 12 to 18 months, get a new physician and remember what Cher says in "Mask": "If I had started to dig a grave every time a physician told me that, I'd be eating chop suey in China by now!"

RADIATION AND KAPOSI'S SARCOMA
by Ken Meeks

KS is one of about 100 or so different diseases we call "cancers." As such, an oncologist may recommend one of the three traditional therapies to attack your KS: chemotherapy, radiation or surgery (which, I understand, is very rare because it leaves nasty scars). Another article deals with chemotherapy; this one is about radiation.

Radiation. Oh, yeah. Three Mile Island. Chernobyl, Indian Point, Shoreham. Yes, and no.

KS is a systemic illness; treatment with radiation will affect only the lesion(s) under the beam--unless you're doing Total Body (more later).

So, your oncologist, in consultation with a radiologist, has recommended radiation for, as in my case, your nose which is purple or your ears which are almost black. Clearly this treatment is for cosmetic purposes, and, I believe, well it should be. You'll show up for your appointment and at this first session, a number of things will occur.

You may be photographed for purposes of keeping track of the progress of the illness and the effect of the treatment. You must be weighed; one of the problems of radiation, which is a danger signal, is weight loss. Then your radiologist will examine you to determine the type of radiation and size of the field to be covered.

Then on to the machine. The radiologist will describe the field to be radiated; the technician will draw in, with a permanent magenta ink, the targeting marks--this permits easier positioning the next time. Everyone but you leaves the room and machine is turned on. About 30 seconds later, you're finished. No smoke, no fire, no foul smell--nothing but the gentle hum of the machinery.

Side effects will include: fatigue, depending on the size of the field; hair loss in the ear covered by the beam; and, depending on a variety of factors, a drop in white cell count. Depending on duration, strength of the radiation and placement, it is possible to get a nasty burn; but this is rare.

My personal preference is for a longer term of treatments of lower radiation intensity--say 200 rads (measure of radiation) for 10 or 15 treatments, instead of 400 rads for 5 or 8. I believe this reduces the burn risk. It's a conservative approach that I like, but it's certainly not a professional judgment on my part.

Last: Total Body radiation. Some institutions have been working on a treatment in which the entire body surface is exposed to radiation for 5 to 7 treatments. I understand this is still in investigative stages; but more importantly, I don't like it. I believe too much good body surface is exposed to get too little body surface with lesions. Check it out if it's recommended, though--just like anything else!

Finally, there is another reason for radiation: to get rid of a specific lesion which is giving you trouble. I had one on the back of my knee; every time I squatted and bent the knee, I had great pain. Everything is much better now.

Radiation, like any other treatment, requires the partnership of patient and physician. Jimmy Hoffa usta say, "Non carborundum illigitmenti est" (or something like that), which translated is, "Don't let the bastards get you down!"

Join the medical partnership, but stay in control.

Health!

VITAMIN E MAY HELP CHEMOTHERAPY PATIENTS
Reprinted from The American Institute for Cancer Research Newsletter

In a recent letter to the New England Journal of Medicine, Dr. Lee Wood, a California physician, reported decreased hair loss in chemotherapy patients treated with Vitamin E.

Before the patients were treated with the chemotherapy drug doxorubicin, they were given 1600 IU (International Units) of vitamin E a day for several days. Although virtually all patients on doxorubicin lose their hair, nearly 70% of Dr. Wood's patients did not suffer significant hair loss.

The psychological impact of hair loss is so intense it can cause some patients to refuse lifesaving drugs. If the results of this study can be confirmed through further testing and research, Dr. Wood believes that "one of the most devastating side effects of cancer chemotherapy will have been eliminated."

CHEMOTHERAPY: AN OVERVIEW
by Tom Flanagan, Volunteer
San Diego AIDS Project

Of the three recognized modes of treatment for cancer--surgery, radiation, and chemotherapy -- chemotherapy is a relatively new procedure. It is a complex form of treatment and often produces uncertain results. Chemotherapy is also one of the more prevalent modes of treatment for Kaposi's sarcoma (KS), the primary skin cancer associated with the current AIDS epidemic.

During chemotherapy, patients are given combinations of drugs at each administration and at varying schedules over an extended period of time. Because cancer is insidious, and because chemotherapy is not able to kill all cancer cells during treatment, enough cells may be left after treatment to regenerate the cancer. However, many types of chemotherapy have been proven effective, particularly when the cancer has been diagnosed relatively early.

Kaposi's sarcoma is a systemic type of cancer. It is generally categorized as multifocal--starting in many places at once--or disseminated--spread to other places from an original source. While surgery and radiation therapy are most effective for cancerous cell clusters that have remained localized, chemotherapy is the most prevalent treatment in use today for systemic forms of cancer such as KS.

Chemotherapy often depresses the immune system even in patients without AIDS-related cancer, leaving them prey for several other infections. In addition, in terms of drug therapy, cancer patients are considered a special case, since it cannot be assumed that their metabolic functions will be the same as for other patients. For this reason, the schedules and dosage levels of drugs given to cancer patients are administered and monitored very closely.

Because chemotherapeutic agents act against healthy cells as well as cancer cells throughout the body, significant physical side effects are often experienced. These include deleterious effects on the bone marrow (anemia, bleeding), the gastrointestinal tract (nausea, vomiting, diarrhea, ulcers) and hair follicles (baldness). Another important physical side effect is weight loss due to both anorexia and diarrhea. In addition to the physical side effects, chemotherapy's impact on the patients work and home life can be severe. However, in many cases, this can be minimized by receiving the chemotherapy on an outpatient basis, particularly if the drugs are given orally, rather than intravenously.

Since chemotherapy treatment must not be worse than the disease the patient should not be given drugs that cause toxic side effects without prolonging or improving the quality of life. The patient should participate with the attending physician in the decision whether to administer or continue a specific chemotherapy regimen. The patient should be made to understand the probable or potential side effects in addition to the overall expectancy of success of chemotherapy, rather than to be merely a passive participant in the process. In this manner, calm and objective decisions can be made which can better result in successful chemotherapy treatments with minimized stress and discomfort.

MY ILLNESS
(SOME THOUGHTS ABOUT AL721)
by M.M.

I noticed a difficulty with my health during the summer of 1985. I had a painful separation from a job. My energy dropped. I attributed it to mental depression.

During the fall I suffered with strange illnesses: an ear infection that wouldn't respond to antibiotics; athlete's foot; frequent colds. In January of 1986 I had the worst "flu" of my life, and it wouldn't go away. Toward the end of the month, I developed a tightness in my chest and a bad cough. Then I went to the doctor. The ELISA test, a T-Lymphocyte subsets and a viral culture confirmed what I did not want to hear. AIDS.

I was given Bactrim for the PCP, and the cough abated. But my strength was gone. I could no longer work. During February and March, I developed painful sores. A fungus spread to my legs and arms. My skin was scaly, with red blotches. I had fits of perspiration at night; I had fevers. I couldn't eat; i became thin. Worst of all was the generalized feeling throughout my body that I was dying. Indeed, I was dying.

My Treatment with Active Lipids (AL 721)

At this time, a good friend of mine--an Israeli citizen--was doing some investigation on my behalf. She discovered a treatment developed at the Weizman Institute of Science in Rehovot, Israel. By express mail she sent me a most remarkable document--a letter full of promise. As I read it, my condition had deteriorated to the point where I had hardly the strength to breathe. I knew my death was imminent.

So I took a leap of faith--I had nothing to lose anyway. After writing goodbye letters to my friends and loved ones, I was taken, in a wheelchair, to the El Al plane, along with my mother and my closest friend. I don't know how I endured that long flight. My Israeli friend met the plane, and took us to our hotel.

The next day I began treatment with AL 721, a potent form of lecithin which makes your cell membranes resistant to viral attacks. It is derived from egg yolks. AL 721 looks and tastes like butter. You spread it on your bread and eat it morning and evening. My Israeli doctor said to me, "The American's don't like our treatment. It's too simple for them."

During the first week of treatment, there was no change in my condition. The three of us were planning how to deal with a corpse so far from home. But after two weeks of treatment, lo and behold! I did feel stronger. My diarrhea seemed less severe. I began to eat. During the first month I gained some weight.

I consumed these Active Lipids through April, May and part of June. When I came back to the USA, I walked off the plane--no more wheelchair. I continued my treatment by taking a heaping tablespoon of granulated lecithin mixed with a raw egg yolk daily. During June my T/4 count continued to rise, even without the Active Lipids. My sores and skin rashes disappeared.

By the end of August, however, the T/4 numbers were heading down again. Since AL 721 is not available in the USA, I once again flew to Israel. Another month of treatment lifted my T/4 number significantly.

"Post AIDS"

In February and March my moribund condition forced me to let go of my plans, my hopes, my loves, my career, my possessions and life itself. The pain was unspeakable. When it came over me that some unfathomable hand of fate had determined that I would not die but live, I became semi-hysterical. I remained that way through most of the summer. Why should I have been allowed to receive this miraculous treatment when it had been denied to so many others?

As I write this, I have no more physical symptoms. The infections have gone; the night sweats have stopped; I have no more fevers. I am able to eat again, and my weight is close to normal. The last symptoms to disappear were the red blotches and scaling on my face. In October, these, too, went away.

I am trying to make sense of all this. I tell my story in hopes that it may help someone. I remain easily excitable. When you have been to Auschwitz and survived, I think you never get over it.

I am proud to be part of a growing company of survivors who have beat this lousy disease. We invite new members to join our distinguished group at any time.

If you wish to contact me, write me c/o P.O. Box 1723, Hoboken, NJ 07030. If you include your phone number, I am likely to telephone you.

AL 721 SUBSTITUTE
(Home Formula)
by Steven Gavin

The following instructions have been distributed at PWA meetings in New York. The text has been slightly changed here, and is reprinted for information purposes only. I am not a physician. More information is available by calling the phone number below. Persons wishing to try this formula should consult a physician.

PC-55 (tm) is a high-strength lecithin concentrate made by Twin Laboratories, Inc., Ronkonkoma, NY. It contains two of the three ingredients of AL 721; they are in a 5:2 ratio, close to the 2:1 used in AL 721. Neutral lipids can be added to PC-55 making it a membrane fluidizer comparable to AL 721. This material is a food nutrient. It is not a drug. It is safe.

Combine five tablespoons of PC-55 and 12 tablespoons of water in a bowl, and whip with an electric mixer. Slowly add 6 tablespoons plus one teaspoon of butter which has been melted. (Measure the butter before melting). Whip thoroughly three to give minutes. This mixture, divided into ten even doses, gives slightly over 10 grams of the lipids per dose. Each dose should weigh about 30.4 grams or 1.06 ounces.

The individual doses can be placed into plastic sandwich bags for freezing. If you don't have a scale, you can measure out two tablespoons to each bag, then add a much smaller amount to divide the remainder. One person separates the doses in an ice-cube tray. Move each dose from the freezer to the refrigerator a few hours before use. This preparation spoils very rapidly at room temperature; it must be frozen unless used immediately.

(An earlier version of this formula used cooking oil instead of butter. The proportions are 5 tablespoons PC-55, 5 tablespoons plus 1 teaspoon oil, and 10 tablespoons water.)

The material is best eaten in the morning, spread on fat-free bread or mixed with fruit juice. The user should eat a fat-free breakfast which might consist of fat-free cereals, skim milk, fruits, or vegetables. There are no restrictions on lunch or dinner. An additional dose might be taken before going to bed. Patients treated in Israel are given two doses a day for about four weeks, then single doses for most of one year. Some People with AIDS might experience diarrhea with the membrane fluidizer, especially with the additional dose. Eat brown rice and other solid foods.

You can help others and yourself by keeping a record of your experience--doses, dates, and any resulting effects.

For more information about the PC-55 home formula, call Steven Gavin, (201) 677-2795. For technical information about AL 721, send a self-addressed stamped envelope to John S. James, PO Box 411256, San Francisco, CA 94141.

MORE THOUGHTS ABOUT AL721
by "HIV Man"

Some of us have concocted what may be called the Poor Man's AL721, even if it does taste much better than that stuff.

Take a cup of orange juice and add 2 heaping tablespoons of granulated soya-lecithin (the Nat-rul brand at Grove Pharmacy is the brand of choice.) Allow the soya-lecithin to be absorbed (about 15 minutes). Put this mixture of O.J. and granules in a blender. Add 2 tablespoons of corn oil while mixing. It makes a sweet emulsion, like pudding and tastes like an Orange Julius. Serve cold. Yummy!

First, it provides a good source of calories. Second, it makes bathroom visits almost a pleasure (if things are a bit loose, eat cheese). Third, your skin will become smooth with a nice feel. Sores will heal quickly. This happens after one week. After a month, you body's cells will benefit from the lecithin, making blood cells less brittle and healthier, just as they claim AL721 does. It is not a cure, but think of it as a therapy during an illness, like a nice hot shower when you have a head cold. You won't believe the difference.

It is also important to warn all of you to think long and hard before getting involved with bizarre treatments. Of course, we are desperate and scared. All the more reason to take your time and use your reason. Many of these treatments are worthless at best, and harmful at worst.

Even seemingly legitimate treatments (alpha interferon and radiation for reachable KS) have done us in. Try liquid nitrogen to reduce the KS. Don't feel sorry for the doctor because there's less money involved in treatment. See if they will treat you without payment. Again, consider carefully any treatment that someone wants to charge you for.

There are volunteer protocols around that just may help, like Naltrexone. Doesn't it make you a bit mad that for five years, these clowns tried to blame HIV on a lifestyle and now they come to the rescue, if you have the money!

It may sound evangelistic, but keep hope alive within you. Don't allow the anxiety of the illness to control your determination. Don't bring yourself down thinking you are unwanted or unloved. Many of us are here and plan to stay that way. It's just too damn bad you can't put some rum in the poor man's AL721!

TREATING THRUSH
by John Gamrecki

For those of you who are tired of buying all those little bottles of Nystatin oral suspension for the treatment of thrush, an alternative is available: pure Mycostatin powder, with a strength of about 1 million units per 1/4 teaspoon (compared to 100,000 units per milliliter for the suspension).

Besides being significantly cheaper than the suspension, the powder has none of the sugar (the suspension is 50% sucrose solution, according to the fine print on the label). Information on dosages and effects can be found in Dr. William Crook's excellent The Yeast Connection (now available in paperback), which everyone with a thrush problem should get ahold of and read. I've had significant improvement on a dosage of 1 million units 4 times daily, but some people may require even more. With only 6 million units per 60 ml. bottle of suspension, you really have to consider buying it in bulk. Avoid the topical powder, though.

Two sources in the city are Freeda Pharmacy, 36 E. 41st St. (685-4980), and Willner Chemists, 330 Lexington at 39th St. (685-0448).

I'd also like to hear from others who are dealing with the thrush problem with either conventional or holistic therapies. Are there alternatives to Nystatin that others have had success with, that I should know about? Does the stuff ever truly go away, or does it just keep coming back? I'm open to suggestions of "whatever works."

PRESCRIPTION DRUGS AVAILABLE AT COST FOR PWAS

Wedgewood Pharmacy, located at 17A East 8th Street in New York City, has set up a system whereby PWAs and PWArcs can obtain prescription drugs at cost.

In a moving letter to GMHC, owners Richard Tauber and Robert Richards explain that "as members of a community, we want to do our part in helping to cope with the AIDS epidemic."

Wedgewood Pharmacy has printed up cards that will entitle the PWA/PWArc holder to specially priced prescriptions. They have asked GMHC to distribute the cards to PWAs and PWArcs; they will also provide eligibility cards to other doctors or agencies that might have contact with PWAs and PWArcs.