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

Case Presentations and Discussions

DR KATZ EN STEIN: Another potential regimen to consider in
this setting is a triple-nRTI combination. If the data that Dr Fischl presented (eg, zidovudine/lamivudine/abacavir) are

confirmed in longer follow-up, then it may provide for yet another alternative.

DR KATZENSTEIN: This is an instance where we clearly
have someone who needs aggressive therapy. Unfortunately,
we do not have good data on the comparative potencies of
different initial regimens in advanced-stage patients
(ie, very high viral load and CD4+ counts below 50 copies/pL)
who are naive to therapy. These are a group of patients where we
want to exert the most potency, and I would most likely
recommend a dual protease inhibitor regimen with 2 potent
nRTIs. The question is whether more patients who have high
HIV RNA levels should take an NNRTI, and we are just beginning
to get those answers. In 1 study, efavirenz and indinavir had similar potency. An NNRTI, a protease inhibitor, and 2 nRTIs might
be a consideration to be brought to the fore. This is where
discussion with the patient about the need to follow through
with each of these therapies is critical. It's our role as physicians
to really stress the importance of this with him and understand
his commitment.
DR VOLBERDI NG: We have seen more data on the use ofhydroxyurea and didanosine at this meeting and I wonder whether we
can consider that as part of initial therapy. We have tended to
think of it more as salvage therapy; would anyone recommend
this for a case like this?

DR MONTAN ER: Dr. Lupo and colleagues presented data from
a study of hydroxyurea as part of an initial regimen. Basically,
the antiviral response was enhanced, and the absolute CD4+ response was dampened. However, the CD4+ percentage response
is actually not dampened. I do think it is a consideration, but its
effect on the absolute CD4+ count may be a bit problematic for
this patient.
The other issue is whether or not patients with higher plasma
viral load levels require more aggressive therapy and the answer is
that we do not know. In analyses of various studies, there is a consistent trend toward a decreased response as the pretreatment
viral load increases, and so one is tempted to assume that adding
more treatment may help. But adherence is the major problem, so
this is a difficult question and we need objective data.
Finally, we have seen good data regarding the effectiveness of
triple drug therapy that includes an NNRTI (Dr Vella's group with
nevirapine and Dr Staszewski's group with efavirenz, for example)
in the context of initial therapy for patients with high viral loads.
DR MELLORS: Personally, without controlled trial data on the
use of hydroxyurea in advanced disease with low CD4+ cell
counts, I would not be inclined to recommend it.
DR HAMMER: It is clear that there are different options for what
one might initially choose. This case illustrates the importance
of early and intensive monitoring of the therapy. The early virologic response is an important predictor of a durable response.
Specifically, assessing the viral load at the 4- and 8-week marks
will help you to know if the regimen is successful, or if it might
need to be changed, or even if intensification of the regimen
might be considered.

VOLUME 6, OCTOBER 1998