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About Just out. (Portland, OR) 1983-2013 | View Entire Issue (Dec. 20, 1996)
ju st o u t ▼ d a c tm tiw 2 0 . 1 0 9 0 T 13 T REASONS FOR HOPE The g rea t d eb ate he latest and perhaps best advice from many leading researchers who spe cialize in the field of HIV treatment is to “hit hard, hit early.” This means “Hit hard, hit early,” or wait until more data comes in about tightly controlling HIV as soon as possible by taking combinations of antivirals that the new drugs and their long-term effects? drive down the amount of virus in the blood to ▼ undetectable levels. There are sound arguments behind this recom by The Boston AIDS Writers Group mendation, but many practicing physicians and people living with HIV disease remain hesitant. There would be no debate if there were an antivi ral that always worked to stop HIV and had no side effects. But so far, every combination has had side effects and limitations whose long-term im plications are unknown. Hence the debate: Should people follow the new advice and hit the virus as hard as possible immediately with the drugs now available, or follow a less stringent course while waiting for more information and better drugs? Many studies show that most people can now reduce the amount of HIV in their bloodstream (viral load) to levels that are not detectable by current tests. Should doctors and people with HIV do anything they can to achieve this effect? For people with full-blown AIDS, the answer is an emphatic yes. This is the only strategy that can H olding S omething in H itting H ard : lengthen lives and ward off opportunistic infec tions. Unfortunately, not everyone with AIDS R eserve : F or and A gainst T he R ules to F ollow can get their viral load low enough, given the drug There is no doubt that some people feel afraid The hit hard approach can involve some risks. options presently available. For this population, to use the most powerful antiviral combinations, It reduces viral load to undetectable levels about hope depends on the ever more powerful combi leaving nothing in reserve if they don’t work. 60 percent to 90 percent of the time, but there are nations now being developed. One reason for waiting to use a hard-hitting no clear options for people for whom it does not On the other hand, there are people with HIV work. An aggressive treatment regimen can be combination is that it is unknown whether the use where the “hit hard, hit early” approach is only of these drugs forecloses future options. It is like putting all your eggs in one basket. If it does one of several possibilities. The latest antiviral possible that using a particular antiviral now, for not keep viral load in check, for whatever reason, combinations are impressive, but they have a example, will take away the option of using others it may take away the chance to use these kinds of limited track record. Soon much more will be later (perhaps even those not yet available). Wait drugs, and perhaps even some other antivirals, known about the growing array of drugs in the ing for more information before using a very later. The very reason that hitting hard is impor pipeline, so for some people it might be a good powerful combination might be a wise choice. tant, which is to prolong the drugs’ effectiveness, idea to forestall treatment. However, this strategy of holding something in implies that if it fails, future options may be lost. Regardless of health status, it is essential for reserve has one rule you may want to follow. This fact leads to two very important rules for people living with HIV to begin wrestling with Decide what hit hard combination (usually in how to hit hard. treatment decisions, taking into account the central volving a protease inhibitor), will be held in First, if you are on an antiviral or a combina considerations: “What should I take and when?” reserve. Then pick a combination for immediate tion that may not be working, do not just add use, one which has a chance to get viral load down another medication (say a protease inhibitor) on H itting H ard : to undetectable levels, but which does not de top of your current regimen. If the old drugs are no crease the likelihood that the hit hard combination longer effective then only the new drug is actually T he A rgument in F avor will still be effective when needed. working. A single drug, as explained above, will Clearly, holding something in reserve is not a probably stay effective for only a limited amount The human immunodeficiency virus makes choice everyone can make. Many people have used of time before a resistant strain emerges. Instead billions of copies every day, and many of them are up so many antivirals that there are practically no of just adding a new drug, work with your doctor mutations. It is likely that a mutant strain of the options left except one hit hard combination. But to find a new combination that is likely, given virus will eventually become resistant to avail some people, especially those who have never used your antiviral history, to get your viral load down. able antivirals when taken alone (what is known antivirals, may have a chance to get two bites at the Second, take these combinations according to as monotherapy). In order to delay resistance, apple. For example, the antiviral ddl plus a cancer schedule. With hard-hitting combinations, the antivirals are now used in combinations. “Hit drug called hydroxyurea, or the antiviral combina whole idea is to keep viral load down to undetect hard” is an effort to knock down HIV to levels that tion of ddl plus d4T, can reduce viral load to able levels all the time, in order to avoid drug cannot be detected by the most sensitive viral load undetectable levels for some people, leaving the resistance. It cannot be overemphasized that miss tests. (Use a test that measures the lowest possible triple combination AZT and 3TC plus a protease ing doses can cause treatments to fail. viral load. The most sensitive tests available mea sure the virus down to 400 or 500 copies per milliliter, and better, more sensitive, tests should meet. be available next year.) C orrective action taken First, all o f the results of the remaining The good news is that hitting hard usually backlogged specimens were to be returned to works, and works well. Effective use of drug on R oche viral load physicians by Dec. 14. Second, for each indi combinations can reduce viral load to undetect vidual who had a specimen that was not pro able levels in most people and, it is believed, will ACCESS PROGRAM cessed by mid-October, Roche will offer two stop further damage to the immune system. There coupons for future free tests, valid for six This summer this column and other treat is evidence that people who experience dramatic months. In order to avoid a similar backlog, ment information sources announced that reductions in viral load usually get a significant these free vouchers will go out over a period Roche Diagnostic Systems was offering two increase in T cells and fewer opportunistic infec from mid-December 19% to the end of March free viral load tests between June 17 and Aug. tions than those who use other, less aggressive, 1997. If your test did not come back in time, be 16. While about 56,000 specimens were pro treatment regimens. sure to contact your physician and have him or cessed, Roche had miscalculated willingness Such an aggressive treatment strategy has her order your free coupons when they hear on the part of laboratories to take part. This added long-term benefits as well. Maintaining a back from Roche. This is especially important meant that some 24,000 specimens still had low viral load can avoid the problem of drug because physicians will have to check their not been processed by mid-October. Clearly resistance. HIV can only become resistant to the own records to see whose test is coming back this was a problem for people making crucial combination of drugs when it is reproducing in late, as the tests are sent back with codes, not treatment decisions on the basis of these tests. large numbers and mutating. Therefore, reducing names, to ensure confidentiality. While it will not undo past damage, it is viral load to extremely low levels, which means heartening to see Roche make new commit HIV is not reproducing rapidly, should make sure The Boston AIDS Writers G roup ments, which it is hoped they will be able to the drugs will remain effective longer—perhaps indefinitely. T inhibitor still available for later. But for those who have already used many drugs, or whose Tcells are so low that they should not wait, hitting very hard right now is the best option. Soon nearly everyone may have more than one hard hitting way to get their viral load to undetect able levels; most people will then be able to have their antiviral cake and eat it too. W hen to B egin : T he “ H it E arly ” D ebate For people with AIDS, or with high levels of virus in their blood (over 20,000 or 30,000 cop ies), or with fewer than 300 T cells, there is no question on when to begin hitting hard: now. For everyone else, the decision depends on many factors. There are a number of arguments for wait ing. One is that in time, we will know more about available treatments. This is a sensible view for people with not much damage to their immune system (especially for people with Tcellsover about 700, not dropping quickly, and low viral loads). A second argument is that if you are currently healthy, taking strong combinations, which usu ally involves taking lots of pills, may make you feel worse due to side effects. This loss of quality of life may be a factor in deciding to wait. Another argument for waiting acknowledges that if a powerful drug combination fails, there may not be a good combination available later, when it is really needed. On the other hand, some would choose not to wait, counting on the devel opment of other effective combinations and new drugs now being studied. And perhaps the most important argument for waiting is that it is still too early to know the long- range effects of taking hard-hitting combinations for many years. The major argument for not waiting is simple: While you wait your immune system could con tinue to deteriorate. As yet there is no sure-fire way to restore immune function. It appears that the less damage there is, the easier it will be to restore what has been lost. In addition, if you wait too long, your viral load could reach levels from which it would be difficult to lower it back down to undetectable levels. Keep in mind that people with higher viral load have a more difficult time getting HIV under control. Hitting hard is the best way to avoid resistance and prolong the useful ness of the antiviral drugs. While the Boston AIDS Writers Group be lieves that if you use antivirals it should be with the goal of getting your viral load to undetectable levels, the decision on when to hit hard is more difficult. It involves many factors such as what drugs have already been used, T cell count (and whether or not it is falling quickly), viral load, and perhaps most important, whether you will stick to a hard-hitting regimen once you begin. This diffi cult decision is best made on an individual basis with the help of a doctor who knows the latest treatments and understands how best to use them. Of course the truly good news is that we can even have this debate. Until recently no one knew how to get HIV infection under tight control. The fact that we can now choose to hit hard at all is the best reason for hope yet. The Boston AIDS Writers Group consists o f Robert Folan and Lou Pesce o f ACT UP- Boston; and David Scondras, Robert Krebs, Derek Libby and Larry Bresslour from Search fo r a Cure. Search fo r a Cure, a nonprofit HIV treatment and education organization, coordinates the writers group and also organizes the ALERT network, which helps the HIV-affected community to impact on treatment and research issues. For more information contact Search fo r a Cure, 58 Burbank St., Boston, MA 02115; phone (617) 536-2474; fa x (617) 266-0051; or e-mail cslp @ search-cure. org.
