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Do protease inhibitors cure or just postpone?

Oct 15, 1996

I have read several of you're articles and would be extremely grateful if you could answer a few questions. First, do you feel HMO's and other managed care organizations should include such treatments as protease inhibitors in there plans? Secondly, do you believe that it would be more costly to provide protease which could possibly be a life-time commitment or wait and ultimately provide hospitalization to a person who has full blown HIV ? I think I already know you're answer but would like to know the justification.

Response from Dr. Cohen

First, let me answer the question you posed in the title of your question: do protease inhibitors cure HIV disease or delay progression? We know that all antiretroviral therapy delays progression (and death), and that the more effective the therapy, the greater the effect. In the case of protease inhibitors, which are highly effective, there can be a very profound slowing of viral replication and clinical progression. The issue of "cure" or "eradication" is controversial. At this point the only evidence for such a possibility is based on hypothetical, mathematical models. It's much too early to know whether viral eradication can be achieved if you completely suppress replication for a long enough period of time.

Should HMOs and managed care organizations provide protease inhibitors? Absolutely. They are the most effective agents known for the treatment of HIV disease; they are FDA approved; and they are standard-of-care.

Should protease inhibitors be used early, or only after patients develop AIDS? First, you asked which would be more costly. That's hard to say. Protease inhibitors are expensive, but thy also help to prevent very costly complications, many of which require hospitalization and expensive life-long therapy. Therefore, though they are expensive, they may still be cost-effective. I don't believe that good cost-effectiveness studies have been done yet to answer that question. Leaving aside cost, I think that while people with advanced HIV disease will clearly benefit from taking protease inhibitors, they may also have a harder time tolerating complicated combination therapy regimens. Furthermore, we now from our experience with AZT that people who take antiretroviral therapy earlier in the course of their disease get a more prolonged benefit from their therapy than people who wait until they are fairly advanced. I do not think it is acceptable to withhold protease inhibitors from patients just because they do not have "full-blown AIDS." I think it makes more sense to try to prevent that from happening at all.

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