HIV Armageddon: Hit Hard, Hit Early?
An Interview with Dr. Mary Romeyn
"If I was positive, I would go on antivirals within an hour," says Dr. Mary Romeyn, an HIV specialist in private practice in San Francisco. She calls HIV "Armageddon" -- the final battle between good and evil.
Hit hard, hit early? Yes. "First, we know that our bodies reach a set point [the lowest viral load] early in HIV where the incredible virulence of the virus is matched by the incredible power of our immune system," she says. "Second, unlike the virus, our immune system is not replicating. Its ability to replicate is quite finite. HIV re-invents itself every day and a half. We reinvent ourselves every 80 years, if we're lucky. So the virus has an advantage."
"Also, early on the cells that are preferentially recognizing [thereby destroying] HIV are killed off. Past that set point, with a high viral load set point [allowed to occur], we've probably lost HIV specific immune power," Romeyn says.
Treatment -- hard, and early -- helps people fight off new strains of HIV from developing in their bodies and maintain the cell lines they have. Without therapy, she says, "the cell line is over -- good-bye."
Still, she believes therapy continues to be useful beyond that point. There are also treatment advances that are coming, such as mediators that help put out naive cells to recognize [and fight] HIV.
"One guy won the Crixivan lottery. He's out five years on the same regimen suppressed [undetectable]. Some people in my clinic are four years on the same regimen suppressed. It's really hard to do," she admits. Her clinic might be more likely to attract people who also believe in hit hard, hit early. They're not necessarily put on HAART right away. Their emotional and social needs are considered before a treatment is agreed upon. "Immune systems are not the only thing we have to treat," she notes. Beyond that, we have to treat and support the will and character it requires to fully fight this fight.
"Critics like Mark Harrington have to be deeply respected because they live through it. But when others are researchers who don't work in the pit with patients and don't fall in love with them and have to keep them alive, I think they sometimes lose perspective. What's fashionable is not always what's right," Romeyn says. Still, she says, "if someone came in with a set point of 1000 T-cells and 93 viral load, I would feel I can't argue with that kind of success." Treatment then would be deferred with close monitoring. She said research presented early this year points to ways of monitoring how the set point is settling.
She takes issue with the idea that regimens are likely to fail people. "You should be able to suppress them," she insists. "Given a patient who is that aggressive about ordering their life and given the more tolerable regimens we have now, I want to hit hard. Just because there's a lot of mediocre medicine and a lot of mediocre adherence doesn't mean we say, 'forget it.' Strive for excellence." Dr. Romeyn would not list regimens she considers tolerable, because she says such decisions must be highly individualized.
Still, she admits that regimens are less likely to keep advanced patients suppressed, which she believes is only another argument for hitting early. "This is the battle for generations and generations to come. These are our kids and they're dying and we can't let them die."
Dr. Romeyn is the author of HIV and Nutrition: A New Model for Treatment.
This article was provided by Test Positive Aware Network. It is a part of the publication Positively Aware. Visit TPAN's website to find out more about their activities, publications and services.