Perspective: Information, Inspiration and Advocacy for People Living with HIV/AIDS

............ Update con AintiArirals

the process say they believe it would be less intrusive than the mass
of pills they must currently swallow every day. For more information on this and other alternative drug delivery methods, see the
article "Project Inform Drug Delivery Conference" on page 7.
Commentary
Recent reports have shown that about 30% of people in large HIV
clinics are starting to see their viral loads become detectable again
or begin to increase while on protease inhibitor therapy. Adherence
to complex treatment regimens may be one factor contributing to
this, while another may be the inability to put together a truly
highly active and potent regimen in the first place. This is usually
because someone has previously taken most, if not all, of the available nucleoside analogues such as AZT, d4T, ddl, ddC and 3TC
and thus gets little help from this class of
drugs. Other reports, which are very preliminary, indicate that people who switch when
their viral loads initially start increasing may In ME
have a better response to the new therapies we dedicate t
compared to those who wait until their viral We de i
loads return to pre-treatment levels. But this P1 Persl
approach is complicated by the possibility TOm B
that it may cause people to use up all their
treatment options too quickly. Still other phy- Gerald
sicians and researchers are beginning to rec- Jim T
ommend that people switch therapy only
when they have a complete new regimen to and all the othE
switch to, such as a new protease inhibitor system did not M
and two new nucleosides or one nucleoside try hard
and one non-nucleoside RT inhibitor. This
approach is often recommended when a per- Their memory liv
son is stable and viral load is not increasing that r
rapidly, even if it has risen above the limit of tt
detection. Clearly, new therapies with different mechanisms of blocking virus replication

* allowing it to replicate and mutate (missing or seriously mistiming doses);
U waiting until viral load returns all the way to pre-treatment levels before switching, rather than switching earlier, when viral
load starts to increase from the lowest level, and viral replication
is still fairly limited (admittedly complicated by the limited num-. ber of drugs which a person can switch to);
0 switching to a new combination without switching to at least
two new potent compounds.
* The ease with which these situations can occur makes it clear that
it is very important to develop a long-term personalized strategy. around treatment decisions. Articles in past issues of PI Perspective
and other Project Inform publications have
described such strategies, and they have been
featured in all Project Inform Town Meetings! 1Ory held around the country. Strategies should
cover such points as when to switch, how to
his issue of the make that decision, what to take, how to enective to: sure that the dosing schedule can be followed,
and how to keep future options open.:

laSSett
Murray
atzIlff
ers for whom the
ove fast enough or
enough.

Unfortunately, developing such an optimal
strategy is much harder or even impossible
for people who have already taken most or
all the available therapies just to stay alive
long enough to be confronted with this dilemma. It is no one's fault - least of all the
patient's - when the struggle leaves a person
without an ideal set of options. No amount

ies
err

are needed for people who cannot tolerate or are breaking through
on the protease inhibitors.
Research has shown that viral resistance to current therapies remains a complex problem but data have revealed some specific
situations that contribute to therapy becoming less effective, and
these are sometimes avoidable with sufficient forethought. Among
the situations to avoid are:
0 following dosing schedules in a manner that allows blood levels
to fall to the point that the virus is not sufficiently suppressed,

on in the work of conceivable foreknowledge could have
nains. changed the situation. However, some compounds in development are likely be active
against protease inhibitor resistant virus, and
innovative ways of combining existing drugs may also shed light
on how to delay viral resistance. The challenge for those who have
limited choices is to develop a strategy that allows them to extend
the effectiveness of their options long enough for at least two new
potent drugs to become available. Sometimes, this goal conflicts
with other goals of the strategy, such as changing therapy earlier
rather than later once viral load begins to break through. Clearly,
new therapies with entirely different mechanisms of blocking virus
replication are needed for people for whom the currently available
protease inhibitors are not an option. U

PI Perspective...
0 Distributes information on
the best proven treatment
options;
2 Advises on access to
treatment;
0 Encourages personal
empowerment through
active participation in
treatment strategies;
2 Increases awareness of
the obstacles that impede
progress in research.

How often does it come out?
2 We have scheduled three for 1998.
Do I pay for a subscription?
2 It is sent free of charge and is
funded entirely by your tax deductible donations.
What does a donation pay for?
2 A toll-free treatment hotline, this
journal, outreach on early diagnosis
and treatment strategies and efforts
to enable sane research and
treatment access policies.

-"Il

PI Perspective...
not a newsletter,
but a unique tool for change on
behalf of people with HIV.

PI PERSPECTIVE NUIVBER 23 NOVEIVBER 1997

I I