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

* PERSPECTIVE
Information, Inspiration and Advocacy for People Living with /IV/AIDS
On the Road 5571095.0291.049

Between Euphoria and Failure
Nearing the end of the second year of the "protease inhibitor
era" patients, physicians and treatment activists are anxiously
looking for clearer answers about the use of these new drugs.
Thanks largely to the media, public expectations have been driven
so high that no therapy could live up to the promises made for
these drugs.

On the one hand, such optimism has
brought a welcome renewal of hope. Carried to an extreme, however, it also contributes to a disturbing new carelessness
about prevention, safer sex and the all too
real risks still posed by HIV. It is disappointing indeed to realize that the improvements in AIDS therapy could so quickly lead
to increased risk behavior and purportedly
serious philosophical debates about such
topics as "bare-backing." In contrast to the
optimism, however, are reports of high levels of treatment failure, leading pessimistic
voices to renew their belief that all people
with HIV remain doomed to an early death.
From this perspective, it's only a matter of
time before all drugs fail everyone. Neither
point of view serves as a useful basis for
constructing effective long-term strategies
against AIDS.
Those with the most optimistic views must
come to recognize that even the best currently available therapies offer no cure and
that they are not the ultimate solution to
this disease. HIV-infected people should not
assume that the current generation of drugs
will work for the rest of their normal lifetimes, nor that these drugs can be used for
decades without serious side effects, some
of which we may not discover for years to
come. The original hope of a few scientists
that the drugs would result in eradication
of HIV now seems unlikely, leaving only
the option of life-time maintenance therapy -

and no currently available drug or combination is good enough for that. In a broad
sense, the present drugs will almost certainly
fail over time. But this doesn't mean that
therapy, overall, is doomed to failure.
* Cheaper, less toxic and easier-to-use therapies must be developed before we can talk
realistically about life-time management of
HIV disease. Fortunately, such therapies will
continue to be developed, at least as long. as the pharmaceutical industry sees AIDS
* as a profitable market.
Whatever their limitations, the current generation of drugs represents a major advance. over anything we've had before, and the
* full extent of their benefits has not yet been
measured. In the optimal circumstances of
I controlled clinical studies and with careful
adherence, the success of these drugs is surprisingly strong at two years out. Once
people achieve truly "undetectable" levels
of virus on the newer ultra-sensitive viral
load assays, the development of drug resistance is dramatically delayed. We don't
know how long this can be sustained, but
* the duration is already being measured in
years rather than months. Another unknown is the accumulation of long-term side
effects. Recent findings about diabetes and
other metabolic changes, such as redistri* bution of body fat, must be watched very. carefully. However, despite widespread be* lief that these recently reported effects are
* associated with protease inhibitors, careful

* data collection is beginning to question this
assumption. Preliminary analysis of several. case studies suggests that the phenomena
are not associated with any particular protease inhibitor, nor even with the class of
I drugs itself. Rather, it appears that these
conditions may exist across the entire population of HIV-infected people.
Part of the dilemma for patients and physicians is that both sets of facts - the optimistic and the pessimistic - are true to varying degrees with different groups of people.
But there is no way to predict how the
matter is going to play out for any single
individual.. Analyzing Failure"
Rate Reports
A few recent studies have reported "failure" rates on the new therapies as high as
53%, but such figures may be misleading if
taken out of context. In the most widely
quoted study, this percentage includes
people who never responded in the first
place and those who could not tolerate the
* associated side effects, as well as those who
responded initially but later saw a return
of detectable virus. It also includes a high
proportion of people who reported diffi* culty adhering to the strict dosing regimens
required by the drugs.. We've known all along that the drugs work
* much better in people who are just beginning treatment, compared to those who. have been using therapy for years. We've
known that it is difficult for many people
to use the drugs precisely as prescribed and
that any significant or repeated deviation
from the prescribed program would contribute to hastened drug resistance. And it's
been clear from the beginning that side efI fects could interfere with peoples' ability to
* use these drugs properly.

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1965 Market St., Suite 220
San Francisco, CA 94103

Administration
415-558-8669

Fax
415-558-0684

Local Hotline
415-558-9051

National Hotline
800-822-7422

http://www.
projinf.org