Important note: Information in this article was accurate in 2003. The state of the art may have changed since the publication date. I have questions about Salvage Therapy, new treatments, and fusion inhibitors.
My partner has been HIV+ for over ten years now. He stopped his drug treatments as they did not seem to be doing any good. He has lost a lot of weight, particularly around the buttocks and chest (and face), has the runs constantly, and is refusing to go back onto medication because he has been told he is resistant to everything that is out there. His CD4 count [T-cell count] is below ten and VL [viral load] up around 1 million. I keep telling him to find out more about salvage therapy and the new treatments that might be just around the corner - but he doesnt make any effort (wants to leave it all up to his Dr. - yet he doesnt tell his doctor everything, including when he stops his treatment). Earlier this year he was on T20 (a fusion inhibitor), but stopped taking it because it was painful and he didnt feel it was doing him any good. My questions are:
First Question:- Can you tell me where I might find some good information about Salvage Therapy - the theory and practise behind it? Research on its effectiveness? Success rate in restoring the immune system? Recommendations for a this strategy?
Second Question:- Can you tell me what are some of the new drugs just around the corner? Will they be useful to someone who has developed resistance to all the current therapies? Will they be easier to take with less side effects? Is my partners immune system restorable with these new drugs given its poor state?
Third Question:- My understanding is that the fusion inhibitor acts on the outside of the cell. Given this isn't it unlikely for HIV to develop resistance against fusion inhibitors? If sustainable treatment for HIV is found is it most likely to come from this class of drugs?
Many thanks.
First, I hope you are doing ok with the stress of a difficult situation.
So called "salvage situtations" are difficult, but not hopeless. They do require lots of cooperation between doctor and patient, but there are strategies to deal with resistant virus, and there is much research in this area.
First, as you may have read, "resistant virus" pays a price for the ability to grow in the presence of drug. Many of the mutations needed for drug resistance seem to make the virus weaker, and a person may be able to live better with medications and a detectable viral load than with no medications and a "wild-type" virus that is more destructive. Many patients are doing well with relatively high viral loads and resistant virus.
Ideally, you and your partner should talk to his doctor about the situation, and work with him to find the combination that works best for him. It might also be interesting to check in with an Adult Aids Clinical Trial Group in your area, and see if they have any "salvage" studies going that your partner might qualify for.
T-20 is a good drug, and has helped many, but as you have seen, it is not very easy to use, and the injections are a problem. Resistance can be seen to this drug, too. A pill form of the drug should be available in the next year or so, and there are also other fusion inhibitors in testing that may work especially well in combination with t-20. In addition, new types of protease inhibitors (tipranovir) are on the way that may be very active in patients with resistance to current PIs. New NRTIS and NNRTIs are similarly on the way. Integrase inhibitors are coming, painfully slowly. There are other drugs of entirely new mechanisms of action on the horizon, too.
To some degree, it sounds like your friend has given up. I understand the battle fatigue, but I have to say that in terms of coming therapies, there could be some major advances just over the horizon. In many ways, I am more optimistic now than I have been for a while, and I would try to convice him to hang in there a while longer- it could have big payouts later.
Your friend is clearly having problems, as measured by weight loss and diarrhea. For now, I would also really push nutrition, in the form of Ensure and supplements. If he is depressed, and this is contributing to his resistance to treatment, this could also be caused by disease.
I hope this is of some help. Please let me know if I can be of any further assistance.
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