Tim Horn Comments On the Future of HIV/AIDS Research
Tim Horn: Treatment advocate and educator in New York
Reading through the volumes of research reports generated over the last five years, one could be forgiven for reaching a rather grim conclusion: that clinical research has been more about HIV itself than about how best to treat people who are infected with the virus. Even with the twilight of the eradication hypothesis, the research agenda is unrelenting in its obsession: How soon should we start therapy to hit the virus? How many drugs should we use to push it to undetectable levels? How long can we maintain control over HIV's wily behavior? Faster. Harder. Longer. Yet, while there is much to be said for the virus hunters and their medical machismo, HIV remains one of the most aggressively treated diseases known to man for which there is no chance of a cure.
Figuring out today's top research priorities requires that we ask ourselves a much larger question -- to what extent do our efforts to battle this virus actually translate into truly feasible health care? For example, it is still not entirely clear when therapy should be initiated. After all, the potential benefit of early therapy is still theoretical, whereas the possibility of long-term side effects is very real indeed. Instead of controlled clinical trials -- not a single study has actually been conducted to determine the best time for people to start therapy -- researchers have drawn upon a hodgepodge of laboratory and observational studies to contend 'the earlier, the better.' Only well-designed studies will actually tell if someone who starts therapy with a CD4+ cell count of 500 actually does better in the long run than someone who waits until their CD4+ cell count falls to 200.
The issue of when to initiate therapy is only the tip of the iceberg. For every one person currently contemplating when to start treatment, there are nine others who are already up to their ears in triple-drug therapy. What is the best option for people who show signs of drug resistance? The majority of researchers, again drawing upon theoretical principles, dictate that the first sign of viral rebound warrants a switch to a new batch of drugs. But what about patients who see their CD4+ remain stable or continue to increase, long after viral load rears its ugly head? Is it possible to keep these patients on their current regimen, thereby preserving future options and delaying a litany of new side effects that may come with switching?
It also seems as if the issue of structured treatment interruptions -- what many of us rightfully call drug holidays -- has already been written off as a potential disaster by many researchers. "Viral load increases when therapy is stopped!" bemoan some researchers. "CD4+ cell counts drop as well!" cry others. Well, of course they do. But a central question remains: Do drug holidays or, quite possibly, pulsed therapy approaches (i.e., treat when the CD4+ cell count is low and stop when it stabilizes) reduce the risk of side effects or help reverse side effects that have already occurred? Will they encourage patients to be compliant with their therapy, knowing that a break is just around the corner? More importantly, are the risks of these approaches any worse than the risks of lifelong, unrelenting therapy?
Perhaps once we put the people living with HIV, and not just the virus, back into research, we'll find the answers we invariably need.
This article was provided by AIDS Community Research Initiative of America. It is a part of the publication CRIA Update. Visit ACRIA's website to find out more about their activities, publications and services.