(RITA!) HIV Treatment Alerts - May 2003

Two steps back. . .

Trizivir has been marketed as a 1-pill, twice-a-day complete regimen, but this may have been premature. On March 10, 2003, a Notice to Physicians was sent out by the Division of AIDS at the National Institute of Allergy and Infectious Diseases. This notice was sent to update doctors and healthcare providers on a government study (ACTG A5095), which looked at 3 anti-HIV treatment combinations that did not include protease inhibitors. The 3 combinations were:

A) Ziagen, Retrovir, and Epivir (a combination also available in one pill known as Trizivir)

B) Ziagen, Retrovir, and Epivir (Trizivir) plus Sustiva

C) Retrovir and Epivir (a combination also available in one pill known as Combivir) plus Sustiva

A safety review during the study found that the patients taking only Trizivir (arm "A" above) experienced drug failure (drug-resistant HIV) earlier and more frequently than the patients taking the other combinations. This was the same whether those patients started the treatment with high or low viral loads (above or below 100,000). Arm A was stopped immediately and the patients in arm A were given alternative drug combinations. The drugs in arm A (Ziagen, Retrovir, and Epivir) are all nucleoside reverse transcriptase inhibitors ("nukes"). In the past, some research has shown that Ziagen should not be the main drug in a combination if a patient has a viral load at or greater than 100,000. These results suggest that the all-nuke regimen of Ziagen, Retrovir, and Epivir (Trizivir) may not be powerful enough alone to fight HIV. Another concern is that staying on a failing drug regimen (where HIV is resistant) can lead to even more resistance that may rule out drugs not even taken yet. In this situation, staying on Trizivir too long with drug-resistant HIV could wipe out the possibility of using any other nukes to fight HIV.

BOTTOM LINE: If you are taking Trizivir as your only anti-HIV therapy, talk to your doctor or healthcare provider about possibly adding a stronger drug or switching to a new and stronger combination. Remember that it is OK to switch anti-HIV medications if your viral load is undetectable; the drugs you switch from are very likely to work again in the future. If you stay on Trizivir alone, visit your doctor every 2 to 3 months to check your viral load and test for possible drug resistance.

Healthcare or Healthscare: Should people with HIV be concerned?

SARS. The recently discovered disease known as SARS, or severe acute respiratory syndrome, is in the news daily with more cases being reported throughout the world, including the United States. SARS usually begins with a fever (temperature greater than 100.4°F) and sometimes chills, headache, an overall feeling of discomfort, and body aches. Mild breathing problems may also occur in the beginning. A dry, nonproductive cough may develop after a few days. If the condition progresses, breathing becomes difficult and mechanical ventilation may be necessary. SARS is spread through droplet transmission, meaning that the virus is spread when an infected person coughs or sneezes tiny droplets into the air and another person breathes in the droplets. Transmission can also occur when droplets land on an object or surface and a person touches these areas. The common cold is usually spread this way too.

The Centers for Disease Control and Prevention (CDC) have issued no specific SARS guidelines for individuals infected with HIV, but Rhonda K. Smith in the Office of Communications at the CDC cautions that "people infected with HIV or other immune-compromising conditions may be more vulnerable to serious infections like SARS." Ms. Smith explains "people with HIV should follow the same guidelines issued for the general population, which include avoiding travel abroad to Southeast Asia (mainland China, Hong Kong, Singapore, or Vietnam) and close contact with anyone who has recently traveled to these locations." [Editor's note: the city of Toronto, Canada, was also named in a travel advisory that was reversed 1 week later. This situation is very changeable, so pay attention to only the most recent news.] In addition, "healthcare workers are particularly at risk and infection control procedures should be used at all times while caring for patients with SARS." Ms. Smith adds that "CDC scientists and researchers will be looking at various risk factors, including immunodeficiency. In fact, studies are already in progress in various parts of the world." For now, the CDC recommend a common sense approach for HIV-infected individuals: wash hands frequently with soap and water, avoid close contact with persons who have any contagious illness, and try to keep your immune system healthy through proper nutrition, exercise, adequate sleep, and other activities.

BOTTOM LINE: As with any emerging infectious disease, pay attention to the news and follow any guidelines given to the general public. If you have HIV and special instructions are given to people with HIV or weakened immune systems, then follow those instructions. Lower T cell counts may mean being extra careful, but there is no evidence yet that SARS will infect people with HIV more frequently or more severely. Updated information about SARS can be found on the Web at www.cdc.gov/ncidod/sars.

Smallpox. People with HIV should not be vaccinated against smallpox because the smallpox vaccine can cause life-threatening side effects in people with HIV, including blindness, inflammation of the brain, and death. In addition, people with HIV should avoid close contact with anyone who has been vaccinated since this could also expose them to serious side effects. The smallpox vaccine does not contain the smallpox virus. Instead, it is made from a live virus called vaccinia, which is a "pox"-like virus related to smallpox. Because it is live, it can spread to other parts of the body or to other people. The vaccinia virus is spread by touching the vaccination site before it is healed or by touching bandages, clothing, or bed linens that are contaminated with vaccinia. Symptoms of vaccinia virus infection include rash, fever, and head and body aches. Only under special circumstances, such as exposure to smallpox or being at risk for exposure, should a person with HIV consider getting the smallpox vaccine. Currently, response and medical personnel, as well as military personnel are being vaccinated for smallpox. Routine testing for HIV is not being done and vaccination in undiagnosed people could cause accidental illness or death.

BOTTOM LINE: People with HIV should not get vaccinated for smallpox. Your chances of contracting the flu or hepatitis are much greater. Focus on protecting yourself from these threats—keep yourself healthy and discuss getting vaccinated against the flu or hepatitis with your doctor. However, if you know someone who has been vaccinated for smallpox, avoid close personal contact with them for 10 days.

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Copyright © 2003 - Research Initiative Treatment Action (RITA!). Reproduced with permission. RITA! is published by The Center for AIDS. Contact Thomas Gegeny, MS, ELS, Editor, RITA! for permission to reproduce RITA!. tom@centerforaids.org. http://www.centerforaids.org

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