AIDSWEEKLY Plus; Monday, October 26, 1998
Daniel J. DeNoon, Senior Editor
Clinicians face a terrible dilemma when advising asymptomatic patients with established HIV infection on when - and whether - to begin highly active antiretroviral therapy (HAART).
Begin early, some researchers advise, because later there will be a higher virologic hurdle to overcome. Begin later, others recommend, and save potent drugs until the patient's immune system begins to fail.
"The first shot is the best shot," noted clinical researcher Michael S. Saag of the University of Alabama, Birmingham. "Whatever you use first is most likely to be successful."
Saag spoke in a state-of-the-art seminar on antiretroviral therapy at the American Society for Microbiology's 38th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), held September 24-27, 1998, in San Diego, California.
Saag acknowledged that there is a dark side to anti-HIV therapy.
"We should expect treatment failure," he said. "We don't want therapies to fail, but we should be prepared in case they do."
The reality that Saag wants clinicians to face is that HAART is unlikely to eradicate HIV, even when treatment reduces viral loads to undetectable levels for long periods of time. Indeed, evidence suggests that there is ongoing HIV replication even in patients with a viral load lower than 50 copies/mL.
These observations suggest that many - and perhaps all - patients on current HAART regimens eventually will develop multi-drug-resistant HIV.
Thus Saag recommends what he calls the "best-shot palliative paradigm" of treatment: begin treatment relatively early with drugs potent enough to control the virus; choose a treatment regimen that an individual patient can tolerate and find convenient; and keep future treatment options open.
Asymptomatic patients tend to have their CD4 counts drop by about 60 cells/(micro)L per year. Unless a patient is avid for more aggressive treatment, Saag would advise waiting until CD4 counts begin to drop below 500 cells/(micro)L and viral load begins to burgeon. For a hypothetical asymptomatic patient with a CD4 count of 560 cells/(micro)L and a viral load of 70,000 copies/mL, he would recommend beginning therapy with three nucleoside reverse- transcriptase inhibitors (NRTIs) or with two NRTIs and one non- nucleoside reverse transcriptase inhibitor (NNRTI).
But rather than lay down strict guidelines based on T-cell counts and viral loads, Saag asks physicians to individualize treatment to their patients. He suggests a four-step process:
* Select an initial regimen.
* Define the parameters of success. Is undetectable viral load the goal? Or is achieving a viral load below 2500 or below 5000 copies/mL more realistic for the patient?
* Define failure. Is it any detectable virus? Or has treatment failed when virus loads rise above 2500 or 5000 copies/mL?
* Define the next regimen. "This is the most important part," Saag said.
Of course, once a patient has clinical AIDS it's too late to be tentative.
"When you get into this realm, you don't have much time to play around," Saag said. "When you get into a serious situation, you should get more aggressive."
When AIDS occurs Saag would "pull out all the stops" and treat with two NRTIs and two protease inhibitors.
"We are seeing results with this regimen," he said.
981026
AW981012
Copyright © 1998 - Charles Henderson, Publisher. All rights Reserved. Permission to reproduce granted to AEGIS by Charles W. Henderson. Authorization to reproduce for personal use granted granted by C. W. Henderson, Publisher, provided that the fee of US$4.50 per copy, per page is paid directly to the Copyright Clearance Center, 27 Congress Street, Salem, Massachusetts 01970, USA.
Published by Charles Henderson, Publisher. Editorial & Publishing Office: P.O. Box 5528, Atlanta, GA 30307-0528 / Telephone: (800) 633-4931; Subscription Office: P.O. Box 830409, Birmingham, AL 35283-0409 / FAX: (205) 995-1588 http://www.newsfile.com
AEGiS is made possible through unrestricted grants from Boehringer Ingelheim, iMetrikus, Inc., the National Library of Medicine, and donations from users like you. Always watch for outdated information. This article first appeared in 1998. This material is designed to support, not replace, the relationship that exists between you and your doctor.
AEGiS presents published material, reprinted with permission and neither endorses nor opposes any material. All information contained on this website, including information relating to health conditions, products, and treatments, is for informational purposes only. It is often presented in summary or aggregate form. It is not meant to be a substitute for the advice provided by your own physician or other medical professionals. Always discuss treatment options with a doctor who specializes in treating HIV.
Copyright ©1980, 1998. AEGiS. All materials appearing on AEGiS are protected by copyright as a collective work or compilation under U.S. copyright and other laws and are the property of AEGiS, or the party credited as the provider of the content. .