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how long meds work
Apr 29, 2002

dr cohen how long do the meds work? im hiv positive. my dr tells me i can live a full life as long as i adhere to my medications. my viral load is undetectable. my friend who is also hiv positive tells me that the meds only work for 10 years or less. is this true? i want to plan for the future , like getting into a 401 k plan. please lay it on the line for me so i can start planning for my funeral arangements. dr holidiny in the forum said that the meds will make you live a full and normal regular life. but recently i was browsing the forum and in one respond to one patient he said the meds only work for 10 or less years. please lay it straight on the line for me. thx

Response from Dr. Cohen

Well, it kinda depends on two things - #1; whether you're an optimist or a pessimist, and #2; how good I am at predicting the future. So, here are the issues.

It is clear that about 5 years ago, with the principles we now use for treatment, we've learned how to use these antivirals in a way that makes the response durable. We do see people whose viral loads are well controlled year after year as a result. And, with our better, and often simpler combinations, we do see people doing well year after year. So, for the optimist, there is evidence that, if these meds work for 5 years, they could easily continue to work for another 50. And that may well be true. So, is that all there is to it??

There can be viral escape seen however, even in those initially suppressed - that's why we need to continue to monitor the response. So far, it appears that we can often understand why the escape happens. And it comes down to a few, controllable things. First - and often the more common - is missing doses in an erratic way. These meds work because we have a certain drug level of them in a consistent way. And that is what keeps HIV in check since as you hopefully know, these meds don't eradicate HIV from us - they just control it. If the level of drug decreases, this gives HIV the ability to start to grow again. And, for those who don't take the meds in a consistent way, HIV can regrow. If there is not enough medication there to control HIV, but enough to allow HIV to learn what to do to ignore the medication, HIV will usually create resistance to the meds. This resistance then allows HIV to ignore not only that medication, but its chemical cousins. And that is clearly the biggest issue that prevents us having confidence that these meds can last a lifetime -- since rebound with resistance diminishes the number of meds we'll have to reestablish control for the long term. Right now, with as many meds as we have, we still have only about "3 hits at the bat" in terms of controlling HIV based on the problem of reestablishing control after resistance. And this can be the difference between controlling HIV for a few years versus a few decades.

Now, adherence to meds can and does prevent much of this premature virus escape. And, if someone does take these meds day after day after day, it is possible they'll continue to work indefinitely. So is that it?

Rarely we do see rebound anyway. Why is that? Well, there are some rare examples of things that can lower blood levels of these meds even in those taking them correctly. For example, we've learned about two plant based supplements - one from St Johns Wort and another from Garlic (not garlic from food by the way) -- that can lower the levels of the protease inhibitors. And, as with missing doses, this can lead to viral escape. And there may be other supplements out there that some may take, that could lower the levels of the meds. Not every supplement has been checked for this - so that is another source of rare surprise. Similarly, some of the cells in our body have pumps which can pump these meds out -- they are after all not familiar and our cells have ways to protect themselves - and these pumps might lower the levels enough to cause viral escape. Finally, it is possible that reexposure to a resistant strain through unsafe sex or needle sharing could potentially allow a resistant strain to take hold.

But these don't see to be common events - instead - the other main barrier to an indefinite response from the meds are the safety issues. Some people for example have lipodystrophy - abnormal body shape changes from how fat cells store fat in the body - in some places too little, and in others too much. And this can happen even with full viral control. This can lead to problems like not wanting to stay on these meds, since at least some of these side effects are cosmetic in important ways, but not "dangerous" as far as we know. However, other side effects do cause problems, like liver inflammation and other issues - and lead us to switch the meds to compensate. So, the challenge of side effects is another reason that we may not get a lifelong response - if people cannot find a combo that they can tolerate which can "work" to control HIV. Now, to address this, newer meds are recently available, while others are coming, each designed to hopefully improve on the toxicity of the initial ones. And this may allow us to continue to control HIV without these problems in the way.

So... is that it? If HIV is controlled, and I can tolerate the meds -- will they last a normal healthy lifetime? The answer is likely yes. What just likely - why not an absolute no doubt about it emphatic yes? It simply comes down to predicting the future. We've had these combo approaches for about 5 years. And we've had people whose HIV suppression has lasted that long, whether it was their first, second, or even third combo. Who have tolerated the med combo they've been on, or switched to, for that long. And if the first five years predicts the next fifty, then it is clearly possible to have a normal life span. And personally, I believe it is likely that at least some will have a normal life span despite HIV. These factors above are barriers - but can and are being addressed. But.... there have been surprises. And that's where the optimist/pessimist part comes in. Since, with five years down, there are fifty or so more to go for a normal life span... and that's a lot years of learning to go... But so far, for many, so good. And, I think overall, yes, it can last to lead to a normal life span. "Ten years" is an arbitrary bit of prediction based on the pessimist rule of inevitable failure. Which may be right. But may be wrong...

Now, as for a 401K - that's of course another mess... and I wish you luck. Since apparently, the point of that is to actually increase your dollars over time, not watch them perilously decline as they've been doing...



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