Intensify: A Way To Boost Your Cocktail

• Why Might Boosting Help?
• How To Boost Drug Levels and Regimens
• What If I Can't Get My Viral Load To Undetectable?

The goal of therapy, with the present antiretroviral drugs, is to get the amount of virus to undetectable.

If your viral load is above 50 rna copies by 16 weeks, you need to consider some ways to get better results. Either the regimen is not getting enough drug to the virus, or your virus is resistant.

Before changing the cocktail entirely, consider intensification.

Why Might Boosting Help?

Because making a cocktail stronger can overcome resistance.

Think of getting drugs to the virus like getting wet in a rainstorm. In a big rainstorm, you run for an umbrella, and if that isn't good enough, raincoat and galoshes too. Then you can go around and not get wet. You are "resistant" to the rain just like mutations make your virus resistant to an antiviral "rainstorm". But, if it starts to pour like a monsoon, you will still get wet. So if we can increase the amount of antiviral medicine, really pour it on, we might get even "resistant" virus wet and stop it from replicating.

Let's have a heart-to-heart talk about the role of adherence in the failure of HAART.

Often when treatment is failing, a resistance test will find the virus is NOT resistant to the drugs. The most common explanation -- a person is missing doses.

If we find the virus is not resistant to the drugs, then we need to try to find out -- with as much honesty as possible -- if doses are being missed and why.

Studies show that missing 5% of the doses can lead to resistance. Five percent means more than four missed doses a month if you are supposed to take three doses a day.

Keeping on these regimens is very hard work. If you are having any trouble at all keeping on your medicines, talk to your doctor, and your friends right away. Non-adherence is the biggest single reason drugs fail. So in this case of regimen failure, an adherence "boost" is better than drug intensification.

How To Boost Drug Levels and Regimens

Regarding protease inhibitors:

Recent studies show that adding 100 mg of Norvir (Ritonavir) to Crixivan, Fortovase, or Agenerase increases the power of these protease inhibitors tremendously. So much so that the new mix should be used only twice a day, and the amount of protease inhibitor will need adjustment.

In the case of double protease failure:

An Australian doctor named Cassy Workman took some of her patientswho were failing a Ritonavir-Saquinavir combination and put them on Ritonavir-Crixivan. Most of them got their viral load way down to below the level of detection once again. Changing Saquinavir to Crixivan "intensified" this double protease combination successfully, perhaps because it is a more powerful combination, or possibly because the resistance pattern for Crixivan was sufficiently different from Saquinavir.

Abbott Laboratories studied people who used Saquinavir (Fortovase) and Norvir (ritonavir) and who were not doing good enough. They intensified, by adding another drug, usually d4T. Those who intensified went down to undetectable and stayed that way for years.

In the case of NRTI failure:

People who are using Combivir (AZT+3TC) and who are not getting their viral load low enough might consider intensifying by adding abacavir (now known as Ziagen). This makes sense because if Combivir fails, abacavir will not be worth anything anyway, so why not try it out to see if it will help get the virus down? And if you are on ddI or abacavir and want to intensify, adding Hydroxyurea might be of help.

In the case of NNRTI failure:

If you are failing on Viramune (nevirapine) or Rescriptor (delavirdine), adding Sustiva (efavirenz) makes a lot of sense because again, failing these will most often mean failing Sustiva anyway. According to studies, if you add Sustiva you will get about a 50% success rate.

What If I Can't Get My Viral Load To Undetectable?

Some people can't get their viral load down to undetectable even with intensification. If they cannot get an entirely new cocktail, they should consider two options:

1. There are new drugs being studied that may have a 'compassionate use' program. These programs are set up by drug companies to provide experimental drugs on an emergency basis. You can usually find out about these programs directly from the drug companies.

2. A big study at San Francisco General Hospital showed people keep getting benefit from their drug cocktails even when they are failing. Three years after their drug cocktails failed, half of the people who kept taking them had lower viral loads and higher t cell levels than before using the cocktails. People who stopped taking their medicines after the medicine 'failed' had drops in t cells and big rises in viral load right away.

We are on the verge of big breakthroughs in drug therapy. The new 'fusion inhibitors' are working on people who have gone through all their options. A new set of nnrti's from several companies look like they will work after other nnrti's have failed. A new protease inhibitor looks very promising as well. Also, a new kind of drug called an 'integrase' inhibitor is in the test tube.

Until there are new drugs available, intensify, hang on or get help from experimental drug programs. Don't give up.

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David Scondras, longtime community activist and educator, is the founder of Search For A Cure.

If you have any questions or would like to contact Search For A Cure write to 34 Edgerly Road #1, Boston, MA 02115 or call Search For A Cure at 617-536-2474 or fax 617-266-0051, or e-mail at hope@sfac.org. Visit our Web site at www.searchforacure.org.

Search For A Cure is a not for profit organization providing education, promoting access & advocating the basic human right to safe and effective treatment for all people living with AIDS.