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

International AlIDS Society-USA
SECTiION 11: ROW~Ih~a~sYk I i~I~~AA1~(I.II ~~ UIII~U i~~

ell count is 720/1L
A level is 1100 copies/mL

fore serious or irreversible immunologic damage occurs. However,
starting therapy too soon has risks in terms of nonadherence, viral
breakthrough, or viral resistance at a point where the patient is
still very early in the course of disease. We have also learned in the
past couple of years that starting therapy too soon in patients who
have not themselves really made the commitment to the rigors of
the regimens is a mistake.
The decision hinges on the patient's wishes at this point. That
being said, I think he does not yet need to start therapy, because his
viral load is very low, CD4+ count is within the normal range, and
he has, at this point, a low risk of serious complications from this infection. I think that it is not wrong to recommend treatment for
somebody with very early disease, but in my opinion this patient
should be advised to defer therapy. He should be monitored closely.
DR MELLORS: I would add that we need to consider whether this
patient has other than a clade B type virus, if he is not from the
US, because the plasma viral load assays will give a falsely low IlIIV
RNA result in patients who have non-clade B virus.

What are your treatment recommendations
for the patient?
DR VOLBER DING: The first step with this patient is to confirm
the presence of HIV infection, as well as the initial laboratory values. The HIV RNA level is low enough that it is in the range of
false-positive results, and the HIV RNA assays are not designed to
be diagnostic tests. Once HIV infection, CD4+ cell count, and IIJV
RNA values are confirmed, the potential risks and benefits oftherapy can be discussed. Obviously, we want to initiate therapy be
The patient is interested in beginning therapy but has expressed concerns about the
peripheral fat redistribution syndromes developing in people taking protease inhibitors. What are your recommendations
for the patient?
DR MONTAN ER: This patient has a CD4+ count of 350 cells/pL, a
viral load of 35,000 copies/mL, and discussion should be initiated
about therapy and treatment options should be carefully reviewed
with the patient based on the data that we have available. There is a
growing body of data that support a variety of potent regimens, including data from studies such as the AVANTI II, III, and INCAS
IMPROVING THE MANAGEMENT OF HIV DISEASE

trials, as well as those including efavirenz, abacavir, and saquinavir
soft-gel capsules. In these trials, about 50% of the patients have a
viral load that declines below the limit of detection using the most
sensitive assays available and around 70% or so below the 400 or
500 copies/mL limit. So I think that what we need is to sit down
with the patient, carefully discuss the options, the safety, the commitment, the type of adherence requirements, and then based on
that, the patient should make a choice. In this patient, a protease
inhibitor-sparing regimen may be appropriate because of the concerns that were expressed. In the absence of comparative data, the
3 NNRTIs currently available (nevirapine, delavirdine, and
efavirenz) are each regarded as a viable option as components of a
triple-drug regimen, with the specific choice to be based on the individual clinical situation and patient preference.
DR THOMPSON: I agree that we need to take the risk for lipodystrophy seriously. We need to talk with the patient about the possibility that they may develop lipodystrophy even on a non-protease inhibitor-containing regimen. The data are only anecdotal
at this point, but there appear to be several cases of lipodystrophy occurring among patients who are taking potent regimens
that contain NNRTIs.
Q