Improving the Management of HIV Disease Vol. 6, no. 5 [World Conference on AIDS (12th: 1998: Geneva)]

International AIDS Society-USA
CASE PRESENTATIONS AND DISCUSSIONS
On July 1, 1998, the updated recommendations ofthe International AIDS Society-USA Antiretroviral Therapy panel were
published in the Journal ofthe American Medical Association (JAMA). This third report of the panel, which was initially convened in 1995, reflects the continued understanding ofHIVpathogenesis and its treatment.
Currently available potent antiretroviral therapy has been remarkably effective in improving the quality of life and preventing
disease progression in a large proportion of individuals in areas of the world in which the drugs are available. However, the approach
to effective antiretroviral therapy continues to evolve rapidly. Newly available antiretroviral drugs, current data about the relative effectiveness of various combinations of drugs, recognition of unanticipated long-term complications ofpotent therapy, new data suggesting that eradication ofHIVis unlikely after 2 years ofpotent antiretroviral therapy, and the emerging role of more sensitive HIV
RNA assays warranted an update of the panel's recommendations. In addition, the IAS-USA panel on HIV resistance testing released its first report on the clinical potential as well as current limitations of HIV resistance testingfor individual patient management. That paper was published in JAMA on June 24, 1998.
In order to support the clinician and patient in dealing with current therapeutic challenges, the International AIDS SocietyUSA held a symposium on Antiretroviral Therapy on July 1, 1998, at the 12th World AIDS conference in Geneva. Members of the two
panels discussed possible therapeutic approaches for difficult clinical scenarios. The panel's discussions of the specific cases herein
are intended to illustrate the principles of therapy, rather than to dictate a single approach to a particular situation. The discussions
focus in large part on the role ofcurrently available drugs. However, the possible roles ofnewer, investigational drugs, particularly
those that are available through expanded access programs were also discussed.
Effective antiretroviral therapy requires the full understanding of and commitment to, the regimen, and is dependent on close
interaction between the patient and the physician in developing a regimen that is appropriate to the individual patient. In many scenarios, especially in antiretroviral-naive patients with early HIV disease, there is a great deal offlexibility in determining when to initiate treatment, and what regimen would be most appropriate to achieve a durable response. Although therapeutic options are less
flexible for patients with considerable previous experience with antiretroviral drugs, close patient/physician interaction is just as essential.
It is important to note that the symposium took place in July, and the optimal approach to antiretroviral therapy has evolved
further still since that time. This summary attempts to include this new information, but it is important for clinicians to monitor the
new insights in this field, as they affect therapeutic decisions.
SETON:CINCLASPETSOFHI RSTANC ET

DR CONWAY: This is a situation that reflects what many of us
are seeing as the more sensitive plasma viral load assays are being
used more widely in clinical practice. It is now quite clear that
having levels below the level of detection, even with these more
sensitive tests available, does not represent elimination of the
virus from the body. In fact, it may well not represent elimination
of the virus from the plasma. In this context, the difference between a value below detection and measures of 200 or 350
copies/mL may not represent a fundamental change in efficacy of
the regimen. It may simply reflect a mild alteration of the balance
between the host, the drugs, and the virus, at least temporarily,
favoring the virus. Data from Havlir et al and Mayers et al (among
others) suggest that most of these early virologic breakthroughs
are not generally associated with the emergence of viral resistance
and do not necessarily imply that the regimen has failed.
In this case, a review of the regimen and its components is

IMPROVING THE MANAGEMENT OF HIV DISEASE