Your comments please
Oct 17, 2002
The duration of immunologic and virologic responses to successive highly active antiretroviral therapy (HAART) regimens becomes progressively shorter, yet benefits in terms of mortality and morbidity rates seem to be maintained.
They also examined responses to first and subsequent regimens among 1022 HAART recipients with a CD4 nadir < 500 cells/L. The time on first HAART was a median of 11.8 months. For a second HAART regimen, the median response duration was 7.4 months and for a third regimen it was 7.2 months.
The patients most likely to have a durable response to HAART were those who were pre-HAART treatment na, who had a rapid response, and those treated initially with one protease inhibitor, Dr. Palella's team found.
In their discussion, they say that patients may derive clinical benefits from continuing on 'failing' salvage HAART, possibly because of direct immunological effects or from an attenuation of viral fitness. However, they conclude that if "our current indices of response to therapy are accurate, patients clearly derive progressively less benefit from successive and increasingly more complex, more expensive and possibly more difficult to tolerate HAART regimens."
Following that thought, they add that "if physician-prescribed regimens continue to exhaust remaining therapeutic options at a rate that outstrips the pace at which newer and more effective agents become available, will there come a time when we observe a recrudescence in HIV-associated death and disease rates?"
Response from Dr. Henry
Many patients fail their initial potent HIV regimen (that data was based on experience with many regimens that are not as simple or potent as ones we currently use now). The main cause of failure is difficult taking the medications with subsequent low levels of drug and the development of resistance. The next regimen is usually more complicated and less active (since there is now some resistance)--each subsequent regimens has progressively more difficulty achieving success. That data can be viewed either as an argument for starting some of the newer regimens earlier (when there is a higher chance for long-term success) or to be more conservative until we know more and even better drugs are available. The SMART study (CPCRA) is comparing those two treatment strategies. I don't know what is the general best long term strategy for using these valuable drugs. KH
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