by Larry Buhl

LifeGuide [Treatment Horizons]

On December 7, 1995, the FDA approved saquinavir, the first in the class of protease inhibitors which were soon credited with revolutionizing HIV/AIDS treatment. At the Third Conference on Retroviruses and Opportunistic Infections in Vancouver in 1996, there was nearly giddy optimism about PIs. Unlike the older reverse transcriptase (RT) inhibitors, which slowed down the spread of HIV, PIs brought back significant numbers of T cells previously destroyed by HIV. 

The power of PIs proved to be a double-edged sword. The high “pill burden” as well as serious gastrointestinal problems and other side effects caused doctors to put patients on newer meds when they became available. Now PIs are used primarily in later stages of HIV, often in combination with fusion inhibitors which prevent HIV from entering T cells.

After a decade of steady progress and increasingly more effective therapies to manage HIV, the giddy optimism is sobered by the reality of a virus that has remained a longtime companion. The state of HIV/AIDS is now mixed: Prolonged, healthier lives, yet 18,000 deaths annually. Small increases in funding, yet with “abstinence-only” strings attached, plus continual attempts to cut Medicare and ADAP. Less toxic drugs and simpler regimens, yet increasing drug resistance.

According to Craig Thompson, executive director of AIDS Project Los Angeles, today’s treatment and prevention techniques are more complex, presenting ongoing challenges to educators and healthcare providers.

“Conversations in the at-risk community are just not occurring like they were before 1996, because there is a belief that everyone knows about HIV,” Thompson told A&U. One necessary conversation that rarely happens regards the six-month infection window when the viral load spikes after transmission, Thompson added. “That period is driving a tremendous number of new infections, especially among young people. I don’t think we’ve worked hard enough to inform them about strategies of that period.”

The complexity of today’s treatment options presents a challenge for patients and physicians as well, according to Dr. Howard Grossman, executive director of the American Academy of HIV Medicine (AAHIVM). “Fifteen years ago, lay people said they knew as much as doctors about HIV, and some were correct,” Dr. Grossman told A&U. “Since then science has become too complex for most people, and very few really understand the nuances of resistance. This is a big problem since we are seeing a resurgence of hard-to-treat infections, both new cases and patients who have been on therapy for a long time.”

“These drugs clearly have a survival benefit if you take them as required, but our job is not done with drugs,” said Gregg Gonsalves, director of Treatment and Prevention Advocacy at GMHC. “There are two thousand drugs on the market today that doctors can mix and match, but it’s still not enough. We need new drugs for those who are becoming resistant to older ones.”

Drug resistance, however, is less relevant for poor urban and rural people, who make up a greater percentage of HIV infections than they did in 1996, and who can neither afford nor access the latest drugs. “People in power tend not to see the poor. That means care is more difficult to deliver, and that it’s harder to keep [HIV] in the minds of policy makers,” he said.

Dr. Frenk Guni, director of Research and International Programs at NAPWA, told A&U that the unknowns about HIV still confound and present an even greater urgency for a cure.

“Every day we learn new things, but there are still some we don’t know. Why can one partner who is negative have unprotected sex with a positive partner and still remain negative? Also, there is no conclusive data on why HIV is able to learn how drugs are trying to interact in the replication process and then forms resistance to specific drugs.” Guni pointed out an emerging belief that HIV produces copies of itself with “errors,” which increases their likelihood of resistance.

“Nobody knows the long-term impact of taking these drugs for life,” Guni added. “We do know that people taking antiretroviral drugs now have high levels of toxins. We need to focus our efforts on a vaccine.”

Larry Buhl is a freelance writer based in Los Angeles. He has written about politics, technology, healthcare, and culture.

December 2005