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less annoying HIV cocktails
Feb 3, 2004

doc, in the early 80s, azt was the only drug & overdosed but people always said then as they do now, follow what ur doc. says. i'm not trying to be a wiseguy in asking this but here goes: what's wrong with switching meds every 6 mths so you dont become immune(resistant?)to them, like roach poison for roaches? i know the docs of the 80s say that if you switch so often you'll become resistant more easily & they may be rt., but what about switching every month even. these drugs stay in one's blood stream for at least a week after stopping them. anyhow, is the "resistance" factor the only reason one should NOT switch monthly? And 2, why use more potent drugs if side effects will ruin quality-of-life? Is QUANTITY-of-life considered more important and QUALITY. From everything i read, it seems like that's the underlying presupposition. It's as if the underlying theme is "You'll live with stomach cramps till ur 80, if u stay on these 2 protease inhibitors," the most potent-for-me drugs. Are newer drugs becoming more potent against HIV and less potent in side effects against people and what are they? i know i sound beligerent but i dont mean to be. it gets my questions' points across faster (or so i think).

Response from Dr. Cohen

Hey. Points well taken. Here are some comments.

In case it is not clear, even doctors and other clinicians doing this work agree. Quality of life does matter to us. We are NOT trying to cause you side effects. We are partners in the struggle to stop the damage done by this evil virus that causes so much misery and death if we don't stop it. And the tools we have to stop it can do pretty amazing work. But we agree that there are some whose side effects are awful. And so, some are miserable with, or despite "good" counts. And yes we agree: this is a terrible, regrettable, and undesirable trade off. It is however the best we have for some right now. And we agree - this isn't good enough for those who are miserable. So the focus we share - is not that we want you to suffer stomach cramping until you're old and grey. It is that we know that people with HIV can suffer miserable infectious complications of HIV unless we stop this virus at some point. How best to do this - what meds, when to start them, how long to take them, at what dose, and whether to stay on them versus stop them for periods of time to avoid their side effects - are ALL questions we share with you. And there is research going on about ALL of these questions. There really is a partnership, even if it (apparently) doesn't feel that way to you.

Why do we rely on "potent meds" despite their possible side effects? The main answer is to avoid resistance. Here is what we know. When we used weaker med combinations - HIV would be able to create resistance to these meds. And when it did so - it could again start to grow and destroy the immune system, ignoring the meds we've used. It was only when we figured out how to create potent combos - meds that got the virus to "undetectable", that we saw years of benefit and not just months. And again, the problem is that because of the limited number of meds we have, if we have resistance to some meds, and keep losing meds to resistance, we can run out pretty quickly. And then, if we cannot stop HIV, it wins. And the world is full of people in whom HIV is winning. And the misery from losing that battle is one worth avoiding.

So - how to maximize quality of life while creating successful treatment approaches? There are a few things we're doing to define that balance. First is the search for newer and better meds. And we've now got twenty to choose from. And it is fair to say that while these twenty still are not perfect for everyone, we've seen remarkable progress in these years. So that from recent studies - perhaps 80% of those starting meds these days can find a combo on which they'll feel well, look well, and have HIV well controlled, with just a few pills per day. For years. And perhaps even decades. So we're clearly doing better...

And as for dose - we also agree - that one dose for everyone is a tradeoff. We are all interested in the work going on to see how we can best individualize these meds so that no one will either be under-dosed or overdosed. So far that part of HIV treatment research is still in the early stages. Not being ignored - but still something for which we are still learning before we're making widespread recommendations, at least here in the US. But this is yet another aspect of HIV medicine that is being addressed.

Finally - as for medication rotations. If someone is on a combo that suppresses HIV to "undetectable" levels - then why not rotate every once in a while to another combination that can also suppress HIV while having different side effects? And therefore avoid long term side effects and even maybe avoid resistance?

So it turns out that was done in a study in Spain a few years ago. It was called SWATCH. You can read about it on this Web Site as it was presented at the IAS conference in Paris last year. They switched from one triple combo to another after three months, and then back to the first one for 3 months, and then back and forth. And it worked remarkably well - there were great success rates and no one stopped this regimen with resistance to the meds. So this research has been done - and perhaps over the next few years may happen again.

But in sum - at least some, if not most of us doing HIV medicine, agree with you and your goals. To feel well, and look well, without the damage done by HIV. And like you, we want to avoid merely prolonging life if that person is miserable as a result of treatment. And we've got some ideas about how to get there. And yes, newer drugs are coming. Some of them are here and are better than what we've had before. And newer strategies are here and still coming - to minimize med side effects while maximizing their benefits.

And hopefully you can find an HIV practitioner that allows you to feel you've got a partner in the shared struggle against this miserable virus...



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