Second International Congress Drug Therapy in HIV Infection 18-22 November 1994 Glasgow, UK

WHICH ANTIVIRAL AND WHEN?

M. Sande
Department of Medicine, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110, USA

Int Cong Drug Therapy HIV 1994 Nov 18-22;2:Abstract No. 3.1
AIDS 1994, Vol. 8 (Suppl. 4);S2

Several years ago the treatment of HIV with reverse-transcriptase inhibitors became a reality, The first study (002) revealed that Zidovidine appeared to significantly slow the course of AIDS in patients that had already experienced their first episode of pneumocystis pneumonia. This was followed by a study in asymptomatic HIV infected patients with CD4 counts < 500mm, which demonstrated a small but significant slowing to symptomatic disease In patients receiving Zydovine in two different dosages when compared with controls (ACTG 019). Optimism was high that major breakthroughs were just around the corner' and clinicians were hopeful that HIV could be controlled with either single drugs or combinations of drugs which would keep the virus in the proviral form, unexpressed and silent, allowing the patient to live a relatively normal life similar to the treatment of diabetes.

Sadly, we were naïve. Rapid expression of resistance by the virus has limited the effectiveness of the three rt inhibitors currently available and preliminary reports also indicate that resistance will also likely occur with the new class of protease inhibitors. HIV appears to be a much more formidable foe than we had initially predicted and the ability of the virus to mutate around the various inhibitors is unprecedented. Recently the Concord study demonstrated that delaying zidovidine therapy until the patient became symptomatic was as effective in prolonging life as initiating treatment earlier in the asymptomatic phase of infection. There is limited data to support the early use of combination therapy although some experts are currently advocating dual therapy early in the disease in an attempt to slow progression. In initial studies with dual rt inhibitors emergence of resistance did not appear to be significantly delayed. I personally currently support the recommendations of the NIH concensus committee that the decision to initiate antiretroviral therapy is a decision that should be made in collaboration with the patient. I would certainly encourage use of Zidovidine in symptomatic patients and move quickly to ddi or ddc if the patient becomes intolerant to or fails AZT. The treatment of the asymptomatic patient is more difficult and given the current data available would not discourage the patient who wanted to wail to initiate AZT until the CD4 fell to < 200 mm³ or the patient became symptomatic. I would not currently recommend early combination therapy. Hopefully, new therapies or therapeutic strategies will soon become available that will have a more significant impact on slowing progression, if not eradicating this infection.

Presenting author: M. Sande

1994-11-18
3.1

Originally published in AIDS Volume 8, Supplement 4 and hosted with permission of the publisher Lippincott Williams & Wilkins, 250 Waterloo Road, London, SE1 8RD, UK. Tel: +44 (0)20 7981 0700 Fax: +44 (0) 7981 0701

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