A Three-Drug Combination is the Minimum Standard of Care

On December 1, 1998, the Department of Health and Human Services published the latest Guidelines for HIV Treatment. Treatment guidelines are developed by medical professionals, treatment experts and patient groups to provide recommendations on standards of clinical practice for any disease. The guidelines are based on all the cumulative clinical research that has been published in the field and they are intended to help both treating physicians and patients in deciding the most appropriate treatment path for the patient.

The most striking change in the guidelines is the addition of Efavirenz (Sustiva), a non-nucleoside reverse transcriptase inhibitor (NNRTI), to the list of preferred drugs that should be used in combination with at least two other nucleoside analogues. Prior to December 1, 1998, only protease inhibitors were in this category. Under Standard Therapy, the guidelines have moved Sustiva outside of its NNRTI class, differentiating it (supported by clinical data) as possessing potency equal to or greater than the protease inhibitors. The implications of these guidelines for the HIV infected person are numerous.

First, for the treatment naive person, protease inhibitors can be saved for a later time (Protease Sparing). Though not without its own side effects, Sustiva is generally well tolerated and has so far, not shown some of the bothersome effects of the protease inhibitors. Aside from durable viral suppression that has been shown in recent studies, Sustiva can be taken once a day, significantly reducing pill burden.

Secondly, for the person whose viral load has rebounded on multiples of protease inhibitors, Sustiva, in combination with virtually any of the nucleoside analogues offers renewed hope for sustained viral suppression. As with the protease inhibitors, Sustiva should never be used alone or in combination with only one other nucleoside analogue. A three-drug combination is always the minimum standard of care, according to the guidelines.

The guidelines are reviewed monthly and updated quarterly. The next revisions will occur in March. As newer drugs approach the horizon, let's hope for even greater alternatives to fighting this infection.