Guy Pujol Comments On the Future of HIV/AIDS Research
Guy Pujol: Executive Director, AIDS Treatment Initiatives, Atlanta, Georgia
"Treatment is not a science. It is an art."
I use this phrase almost daily as I discuss treatment strategies with people considering their options. We have to understand that there is not one medication or one combination which will work for everyone. Many factors go into determining a first, second, or subsequent regimen. Side effects, food restrictions, and convenience factors all add to the complexity of the decision. And that is just the beginning of the growing complexities of treatment. Resistance, cross resistance, drug-drug interactions and a host of other issues complicate the process even more.
When I attend International AIDS Society symposia, I am constantly amazed at the diversity of opinions regarding treatment strategies held by doctors participating in the discussion. In one part of the symposia, a patient case study is presented to the participants. After the patient's medical history is presented, the doctors in the room vote on which combination they would recommend prescribing next. Using a keypad like the audience uses on "Who Wants to be a Millionaire?" the participants select regimen A, B, C, D, or E. Then the results are projected on a screen for everyone to see. One would hope to see a consensus of opinion or at least a majority favoring one option over the others. But each option often receives approximately the same number of votes. This demonstrates that each doctor considers her or his own set of factors when selecting treatment options -- either different regimens or even whether to treat at all.
In light of this diversity, I believe future research needs to examine the issue of treatment strategy itself more closely. Yes, we need to continue researching new and novel treatments such as fusion inhibitors, integrase inhibitors, and nucleotide reverse transcriptase inhibitors. Personally, I am encouraged by these new classes of drugs that stop viral replication earlier in HIV's life cycle, allowing the T-cell to remain viable (unlike protease inhibitors). However, I think research needs to take a more comprehensive approach to disease management than just attacking the virus.
We are over-treating the virus and under-treating the person. More attention needs to be given to therapies that strengthen the immune system and allow the body's natural defenses to aid in viral suppression. The new generation of antiretrovirals with easier dosing schedules and reportedly fewer side effects is exciting; but they should not be the sole focus of research.
We need more evidence-based studies of the efficacy, advantages, and disadvantages of specific combinations of therapies. For example, long-term side effect studies should not be conducted independent of pharmacokinetic-enhanced regimen studies. New antiretroviral agents should not be studied independent of immune-based therapies and therapeutic vaccines. Studies must begin looking at the potential benefits (and the potential risks) of the next era of combination therapy -- that is, combining antiretrovirals, immune-based therapies, and therapeutic vaccines as an integrative approach to disease management.
The science of treatment and research has been too narrowly focused. Maybe a more artistic approach is needed after all. With art, we do not look at each color or line independent of the other colors and lines on the canvas. We look at everything in order to see the big picture. I am convinced we need to do the same as we look at the treatment of HIV.
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.