AIDS Treatment Update, No. 44, August 1996
Dr Ian Williams

A single measure of viral load appears to be a better predictor of the risk of developing AIDS in the long-term than the CD4 count. Someone with an initially high viral load is likely to have a more rapid fall in CD4 count.

For people who start antiviral treatment, the change in viral load after eight weeks of therapy appears to be the best predictor of longer-term response. People who have a greater fall in viral load in the short-term appear to respond better overall to treatment.

These findings suggest that viral load has an important role in routine monitoring, particularly for patients on anti-viral therapy. However, we still need more research on how best to use these tests in the clinic to help ensure that drug resistance and failure are prevented (or at least delayed) and disease progression halted. Also, the new research does not tell us when is the best time to start therapy.

Results presented in Vancouver reinforced the findings of previous trials that showed that combination treatment is superior to monotherapy. As reported in issue 42, the combination of saquinavir and ddC reduced the risk of further AIDS-defining illness and improved survival, compared to treatment with either drug alone, among patients previously treated with AZT. This is the second study showing clinical benefit of a protease inhibitor, and also indirectly suggests that switching therapy to two new drugs may be a better strategy than switching to or adding just one new drug.

Other studies looked at the treatment of people with primary infection. Using drug combinations within weeks of infection leads to marked falls in viral load and rises in CD4 count, compared to those seen with AZT alone or no treatment. Treatment may also prevent infection and disruption of the lymph glands.

The long-term benefits of treating seroconverters remain uncertain but these early findings are encouraging. They may influence the current treatment of people with primary infection and improve awareness of the importance of diagnosing newly infected people.

In summary, the latest research holds out hope that we may be better able to assess patients' prognosis, to provide genuinely effective treatments, and to monitor the benefits of therapy.

Dr Ian Williams is a consultant at the Mortimer Market Centre in London.

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