Participants: John Coffin, Ph.D.; Joseph Eron, Jr., M.D.; Robert Murphy, M.D.; Giuseppe Pantaleo, M.D.
Moderator: Charles van der Horst, M.D.
A complete summary of this free-wheeling and lively panel discussion of controversies involving antiretroviral therapy would be impossible, but some of the issues discussed included:
1. When should antiretroviral therapy be started?
Some panelists felt that therapy should be started as soon as possible in order to minimize genetic diversity and damage to the immune system. Others felt that delay could be justified if the viral load was low and there was no evidence of immune damage.
2. We all know that you shouldn't add a single drug to a failing regimen, but is it acceptable to add a single drug (such as a protease inhibitor) to a 2-drug nucleoside regimen if that regimen is working?
Again, the jury was out on this question, with some panelists feeling comfortable with that approach provided the viral load was undetectable, and others feeling that low levels of resistance may be present even with undetectable viral loads, which might lead to earlier protease inhibitor resistance.
3. How should we define drug failure?
One panelist defined failure as "detectable virus at 20 weeks in a naive patient who has started aggressive therapy," but pointed out that for a patient with prior antiretroviral experience and more advanced disease for whom limited future options remain, failure should be defined less strictly.
4. What do you do when the CD4 count is inconsistent with the viral load (e.g., when both the CD4 count and the viral load)?
Most panelist felt that you should pay attention to the viral load, which is a better indicator of the current status of the patient, and the speed of their future progression.
5. Can you reuse antiretroviral agents after a patient has been off them for a long period of time?
The answer was a fairly unanimous "no."
6. What is the role for genotypic analysis?
The panelists felt that these tests need to become more sensitive to quasi-species that make up small proportions of the viral pool (e.g., less than 1% of the population), and that until that is achieved, the role for these tests is limited. The tests are more helpful when they are positive (for mutations) than when they are negative.
7. How do you treat HIV-infected pregnant women?
This was addressed in a lecture by Dr. Minkoff the following day. The short answer was "treat the woman the way you would treat her if she weren't pregnant."