Important note: Information in this article was accurate in 1997. The state of the art may have changed since the publication date.
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The San Francisco Examiner - Friday, Jan. 24, 1997
Lisa M. Krieger, Examiner Medical Writer
Only a small minority of the nation's HIV patients are undergoing the potent new combination therapies, which have been proven to reduce blood concentration of the virus to undetectable levels, said Dr. Douglas D. Richman, organizer of the Fourth Conference on Retroviruses and Opportunistic Infections and an AIDS clinician at UC-San Diego.
Delayed, inadequate or intermittent therapy was found harmful to patients and it threatens public health by creating a virus that's impervious to drug treatment.
"This is the surest way to make these drugs useless," Dr. Robert T. Schooley of the University of Colorado Health Sciences Center in Denver and a key organizer of the conference, said Thursday.
The new goal is "complete (viral) suppression - as quickly as possible," said Richman. "Complete suppression of the virus is the only way to go."
On Sunday, the International AIDS Society is expected to release guidelines for doctors that will urge much more aggressive treatment. The U.S. Public Health Service is developing similar revisions to its guidelines.
"The importance of getting people on appropriate therapy is becoming clearer and clearer," said Dr. Paul Volberding of UC-San Francisco and a member of the international group of AIDS experts.
Of the 600,000 to 900,000 Americans thought to be HIV-infected, an estimated 100,000 are on triple therapy, according to pharmaceutical company statistics.
Expanding access to more than a half-million patients will be expensive - about $12,000 or more a year per patient. But there is a strong scientific rationale, experts at the conference said.
The days of watchful waiting - when doctors delayed treatment until the patient began to decline, then administered one drug at a time - seem to have fortified the virus, they said.
HIV learned to dodge each bullet. In Darwinian fashion, the mutant drug-resistant strains escaped treatment and reproduced - and the microbe soon became untreatable.
An estimated 20 percent to 25 percent of patients previously treated with the anti-viral drug AZT are not responding well to therapy with much improved drugs. Treatment failures have also been blamed on resistance to other older anti-viral agents DDC and 3TC.
"When you start treatment, you are embarking on an evolutionary pathway that can't be reversed," Richman said. "When you see a patient, the first thing they start with has implications for the rest of their life."
The old approach "was set up to fail," he said.
By attacking early and simultaneously with a battery of drugs, doctors give the virus no time to multiply and mutate - so resistance is far less of a problem, Richman said.
He estimated that only half of infected Americans know they carry the virus. Of those, half don't get treated. They are waiting, incorrectly, for illness to strike. Or they're not convinced that treatment works.
Of those being treated, about half are getting "suboptimal" treatment, said Richman.
Some doctors are not up-to-date on treatment strategies. Some patients are not adhering to therapy. In other cases, state drug reimbursement programs - such as the Texas Medicaid program - do not pay for triple combination therapy.
The combination approach works because it wreaks havoc with the life cycle of the virus. It interrupts two, not just one, phases of the HIV life cycle. The standby drugs - AZT and 3TC - inhibit one enzyme of the virus. The new protease inhibitors block another. Together, the three drugs have transformed AIDS treatment by forcing the virus into a corner so it can't multiply.
"We should treat to the maximum of our ability, to reduce the risk of resistance," Richman said.
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