AIDS Treatment Update

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Principle three: easy-to-use
Enabling long-term use of a regimen requires
long-term 'manageability' for the person
taking it to be prioritised. Whilst long-term
adherence is about others things as well as
this, taking treatment which impinges on
quality of life will always be an uphill struggle.
The number of pills to be taken, the number of
doses per day, and the food, drink and fasting
requirements of a regimen will be important to
fit with the individual's daily activities and
with their preferences.
Principle four: safety & tolerability
All drugs are associated with unwanted
effects, but they may be more or less

PI [protease inhibitor] see pages 4-5
NNRTI [non nucleoside reverse
transcriptase inhibitor] see pages 6-7
NRTI [nucleoside reverse
transcriptase inhibitor or nucleoside
analogue] see pages 8-9
significant to different individuals. For some,
central nervous system side-effects may be a
less worrying prospect than diarrhoea, and
vice versa. Avoiding side-effects which impact
negatively on quality of life is an important
end in itself. The tendency for drug-related
symptoms to interfere with adherence is
another reason to prioritise tolerability.
The issue of tolerability is the counter-balance
to the desire for potency. So while regimens of
four, five and six drugs may offer greater
potency, the reason these are not standard
options for first-time therapy is because they
would likely result in a unacceptable level of
side-effects.

cross resistance
Viruses resistant to one
anti-HIV dingare
often resistant to other
similar drLigs as well.
Changing to an
effective new cling
combination in these
circnmstances may be
ciffirn It. This roblem
affects all classes of
anti- H IV drngs. E.g.
developing resistance
to one NN RTI is illcely
to stop yoLu benefiting
from other available
drugs in that class. This
is a key reason why
regimens containing
drugs from each class
(PI, NNRTI, NRTII are
rarely used first-line. If
resistance to all
classes develops,
finding an effective
second regimen will be
hard.
sequencing studies
Two large international
stncies are investigating
the longer-term
outcomes of differently
seqenced anti- H I V
d ruig regimens. I NfITf10
is recruiting participants in the UK. A US
stncdy, ACTG 384 closed
to recruitment a year
ago, and may report
initial results in 2001.
further reading
The subject of this
special issue has been
previously covered in
issues 83/ 76 and 68,
and more detailed
reviews of the issues
raised, clings cdiscuissed,
and cnrrent 8UK clinical
trials can he found on
N A Ms welbsite
aidsmnia p.com.

which first-line anti-HIV combination is best?

" There is no clear evidence as to which of
the currently available drug combinations
is best for people starting HIV treatment,
so doctors advise choosing drugs according
to the individual needs of the patient.
" It's usual to begin with three drugs, two of
them being nucleoside analogues (NRTIs).
m A combination of one NNRTI and two
NRTIs appears at least as effective in
reducing viral load below 50 copies as a
combination of a protease inhibitor (PI)
and two NRTIs.

*A combination of three NRTIs is
another option, but in the past this has
appeared less satisfactory therapy for
people who begin treatment with high
viral load.
0 There is a relative lack of evidence
about the effects of regimens with an
NNRTI or a third NRTI in people with
advanced disease, compared to PIs.
N The longer-term safety of anti-HIV
therapy is an ongoing concern that
affects all drug classes to an extent.