United Press International - Wednesday, 12 July 2000
Michael Smith, UPI Science News

But if the best therapy costs too much, the society said at the 13th International AIDS Conference, doctors in developing countries can resort less effective and riskier methods, even though they are now rarely used in the West.

"There is one standard of care, " IAS President Mark Wainberg told reporters. But Wainberg acknowledged that the multi-drug cocktails used in the developed world are beyond the financial reach of most people in poorer countries.

In that case, he said, the guidelines allow physicians to use less-effective two-drug regimes, which are no longer widely used, since the three-drug cocktails started being prescribed in 1995. Those two-drug regimes are thought to be risky, because they could create drug resistance in HIV, the virus that causes AIDS.

They are also less effective than the three- and four-drug cocktails in suppressing the reproduction of HIV, the guidelines say.

The two-drug combinations usually use a class of medications called nucleoside reverse transcriptase inhibitors; the new cocktails drugs from a class called protease inhibitors.

"It's complicated," Wainberg said, "because there's a lot of evidence the double therapy will keep you alive for a while...but there's no assurance people will do as well" as they would on the three-drug cocktails.

Eric van Praag of the World Health Organization, which helped draft the guidelines, said: "There is one standard and there is reality."

The reality is, he said, that even a less-than-perfect drug therapy is better than nothing. But van Praag added that anti-HIV drugs must be accompanied by counseling on side-effects and safe behavior.

As well, he said, there must be consistent medical monitoring to make sure drug resistance does not occur and that so-called "opportunistic infections" -- such as tuberculosis -- are treated before they become serious.

Italian researcher Stefano Vella, the incoming president of the IAS, said the problem is to "minimize the harm of double nucleoside therapy when it is used."

But physician David Wilson, who works with Doctors without Frontiers in Bangkok, said it's wrong to say there's a single "gold standard" of care. Even in the United States, he said, many doctors still prescribe two-drug combinations for patients whose immune system is still strong.

In fact, he said, most Thai AIDS patients are on double therapy and it is "useful."

Nairobi physician Christopher Ouma said the scientific desire to have the best possible result must give way to the "human aspect -- we have patients who are dying for lack of these drugs."

Access to drugs has been a major theme of this conference, the first International AIDS Conference ever held in the developing world. The IAS guidelines, Wainberg said, are an attempt to reconcile the lack of access with the best available treatment.
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