AIDS Treatment News
June 21, 1996

New Optimism 
on Controlling HIV Infection

In late January of this year, at the Third Conference on Retroviruses and Opportunistic Infections, early data from at least two small trials suggested that, under ideal conditions, certain drug combinations could reduce all evidence of viral replication to undetectable levels in most patients. And the proportion of patients achieving this success seemed to increase over time -- the opposite of previous experience with anti-HIV drug treatments, which quickly reached a peak of viral suppression and then steadily lost effectiveness.

Today there is more data, and from different kinds of patients, suggesting that:

1. Under ideal conditions -- meaning that treatment is started early, using certain antiviral drug combinations, in patients who are previously untreated (at least with all of the drugs in that combination), and with patients who can and do comply with the treatment regimen by using the drugs as directed -- HIV replication in many patients can indeed be reduced to levels which are completely undetectable by any test known, for prolonged periods of time. No one knows how long this essentially complete shut-off of viral replication will last, because the trials are only running now; but in most of the patients who can achieve this suppression and who can continue using their treatments as directed, there seems to be no evidence yet that this antiviral success is coming to an end. Some people have been on treatment in the studies for well over a year.
2. If viral replication can be reduced to undetectable levels, patients do not progress to more serious disease, in the time frame seen so far. Again, no one knows how long this will last, since there is no long-time experience yet with patients whose viral load has been greatly suppressed by drugs.
   Advertisement
   Also, there are anecdotal reports of substantial improvements in ongoing AIDS-related symptoms in some of the patients. (There is no scientific data yet on this finding, as trials designed to address this question have not yet been run).

   The viral load in these patients is lower than that in long- term nonprogressors, who remain disease-free for many years, possibly indefinitely in some cases. But the number of persons who are naturally long-term nonprogressors (without treatment) is low, probably about five percent or less. By contrast, it appears that currently available drug treatments -- when used under ideal conditions -- can suppress all evidence of viral replication and disease progression in most patients, for an unknown period of time.

3. The major problem in treating HIV has been that the virus develops resistance to all known drugs, causing treatments to lose effectiveness. It has long been known that the time required for resistant virus to develop varies greatly, depending on the drug. For example, with nevirapine (an experimental treatment recently recommended for approval by an FDA advisory committee), high-level resistance occurs very quickly if the drug is used alone. But AZT resistance develops more slowly, and some patients can use that drug for years without it happening (although there is increasing concern about people being infected with virus which has already become resistant to AZT -- and also concern that some AZT-resistant viruses may be more harmful than most non- resistant viruses, even aside from the problem of loss of effectiveness of AZT).

   But now there are trials of antiviral drug combinations active enough to reduce viral replication to undetectable levels in many patients. And it is being learned that when viral replication is reduced to a low enough level, the development of drug resistance is greatly slowed, or possibly even stopped. The example of nevirapine shows how large this difference can be, since resistance develops rapidly if used as a single drug or a single addition to ongoing therapy. But in the right combinations, for patients previously untreated with any of those drugs, nevirapine appears to be useful for a long time.

4. Like almost all treatments for infectious diseases, this approach works best when treatment is started early -- and when patients do not already have resistance to any of the drugs in the combination they are starting (either from previous use of a drug in a dose which was not effective in shutting off viral replication, or by infection with virus which was already resistant). But there is no known reason why the same approach could not also work in advanced patients who have had many previous treatments, provided that some way could be found to reduce viral load to a low enough level. The problem is that it will be more difficult to find drug combinations which can do this for persons with more advanced HIV disease. This is why it is important to develop new and more powerful drugs, and better information about how to use them in combination, and about what treatments work best for different kinds of patients.

The emerging view of experts today is that what counts is getting the viral load very low and keeping it very low, regardless of how this is achieved -- whether naturally in persons fortunate enough to be long-term nonprogressors, or by whatever antiviral combination works for the particular patient. The more advanced the illness, the higher the viral load is to start with, the more drug-resistant viruses the patient already has, and the more problems there are with continuing the drugs and using them as directed, the more difficult it will be to get the viral load low enough. To maximize potential benefit, the emerging treatment philosophy is "hit hard and hit early."

How low a viral load is low enough? No one knows for sure at this time. A viral load which is and remains below the limit of detection of the Hoffmann-La Roche Amplicor HIV-1 Monitor(TM) test -- the only viral load test currently approved by the FDA -- would seem to be a reasonable goal for now; for more information, see "HIV Viral Load Markers in Clinical Practice," published in NATURE MEDICINE, June 1996 (reviewed in AIDS Treatment News #248, June 7, 1996). [As we reported in our last issue, two free tests to establish a baseline are being offered to everyone with HIV in the U.S., but only for a 60-day period beginning June 17, 1996; for more information, call 1-888-TEST-PCR.]

Is Viral Eradication Possible?

If viral replication can be essentially completely suppressed for a long time, is it possible that the virus remaining in the body would eventually die, meaning that HIV was eliminated and the person could stop taking the drugs and would be cured? This is conceivable, but at this time there is no evidence that this is possible. Eventually some people whose virus is now being completely suppressed by antiviral drugs will try going off the drugs, and then we should find out quickly whether or not the virus comes back. (Two patients who had undetectable viral load for two months and four months did interrupt therapy, and the virus returned; this was reported by Dr. Luc Perrin, of Geneva University Hospital, at the recent HIV Eradication conference mentioned above.)

Although there is no evidence today that it is possible to eradicate HIV in an infected person, what is new is that the question is now open. Until recently, all drug regimens had been observed to fail with time; therefore, there was no possibility that any amount of those treatments could eliminate the virus. Today, with better treatments, we do not know. But even if it turns out that HIV cannot be eradicated just by suppressing it completely enough for long enough, the new results would still suggest that for many patients viral activity can be stopped for a long time, and drug efficacy maintained, with combinations of currently available drugs.

Comment: Practical Concerns

Most of the drugs being used in the new trials which appear to have largely shut off HIV replication in many patients are already widely available (in the U.S. and some other countries), by prescription or through expanded-access programs. The researchers running the trials have been unwilling to recommend particular combinations, since what counts is getting the viral load low enough, and the best drugs to use for this purpose will vary depending on the patient. Most of these regimens combine a protease inhibitor with at least two other antivirals. We will report results of particular drug combinations with particular patients as more information becomes available.

One of the practical difficulties in implementing the "hit hard and hit early" strategy, as the new results suggest, is that it means that people in early illness, who have no symptoms, are expected to begin long-term (possibly life- long) therapy with combinations of at least three drugs. All these drugs can have side effects -- and all are expensive, and often inconvenient to use (as most must be taken twice a day or more, some on an empty stomach, others with food, etc.) How many people will be able and willing to begin and stay on such multiple-drug treatment, when they feel completely healthy, and may understandably be inclined to leave well enough alone? How many will be able to pay for expensive treatment (especially when their insurers see that they appear entirely well)? The new results seem to suggest that everyone who is HIV-positive should be on aggressive treatment with multiple antiviral drugs. But how realistic is this?

It seems to us that the widespread use of very early, very aggressive treatment will in practice usually wait until more evidence becomes available. Much more will be known by later this year. And it is possible that persons with a naturally low viral load might need less aggressive treatment to achieve the suppression required. It is also possible that after a period of suppression, maintenance therapy might not need to be as aggressive as the initial therapy. But this is only speculation until more is known.

Meanwhile, physicians and patients should re-think the unfortunately common practice of beginning HIV treatment with AZT alone, or with other regimens not strong enough to suppress the virus sufficiently. This approach is likely to lead to resistant viruses, which might make future treatment more difficult than if the inadequate treatment had never been started at all.

Internet Free Speech 
Wins Court Test

The June 11 decision does not affect the laws against obscenity and child pornography, which remain illegal on the Internet as elsewhere. But the "indecency" standard is much more far-reaching and vague than obscenity. For example, unlike obscenity, indecency "has not been defined to exclude works of serious literary, artistic, political or scientific value" (quotation from the court decision). The new ruling essentially gives the Internet similar First Amendment protection to what books, newspapers and other print media now have, instead of imposing the much more restrictive standards now applied to broadcast radio and television, which the Communications Decency Act would have done.

The decision includes an excellent summary of the technology and history of the Internet; we learned much from it. Also impressive is its review of the recent history of the First Amendment, and explanation of the reasons free speech is important in our system of government and society. The court also noted that there are effective ways to keep unsuitable material away from children, without restricting communication among adults.

The decision took particular note of the "market failure" by which both broadcast and print media have largely become controlled by a few large institutions, with most peoples' participation being passive -- and how the Internet is fundamentally different, with much lower barriers for entry, and essentially the same low barriers for speakers as for listeners. The Court clearly understood that the new law would have a disproportionate effect on individual citizens and on small organizations, while large corporations could protect themselves through expensive legal defenses, and by limiting their material to the mainstream viewpoints that we now receive through the broadcast and major print media. (The Court also noted that the new law would have little effect on commercial pornographers, who already exclude children by requiring credit cards for access to their materials, and therefore would not be much affected by the CDA.)

The historic importance of this ruling cannot be overemphasized, as many experts suspect that computer communication will become as important as the printing press in human cultural development. The new law would have effectively required adults to limit their use of this medium to communications suitable for children.

The case which led to this decision was brought by dozens of organizations and companies (in two separate legal actions which were later combined), including the American Civil Liberties Union, American Library Association, American Society of Newspaper Editors, Apple Computer, Microsoft Corporation, America Online, CompuServe, The Microsoft Network, and Prodigy. AIDS organizations included AEGIS, Critical Path AIDS Project, and The Safer Sex Page.

The decision provided sound bites which were quoted again and again in the media:

"The Internet may fairly be regarded as a never-ending worldwide conversation. The Government may not, through the CDA, interrupt that conversation. As the most participatory form of mass speech yet developed, the Internet deserves the highest protection from governmental intrusion."

The full text of the decision is available at various Internet sites, including http://www.aclu.org. AIDS Treatment News followed the development of the CDA in issues # 227, 229, 236, 237, 238, and 240.

Azithromycin Approved for Once-Weekly 
MAC Prophylaxis

Azithromycin has been approved in the U.S. for other uses since 1992. The new approval for MAC prophylaxis should help to educate physicians about this treatment option, and also help in getting reimbursement for the drug.

According to Pfizer, its drug "will be available at a lower cost than currently used MAC prevention therapies." The company has a patient assistance program to help some patients who need the drug and cannot afford it.

Nevirapine Recommended for Approval

Nevirapine was recommended for use in combination with other antiretrovirals, because when the drug is used alone, viral resistance develops quickly. In triple combination with AZT plus ddI, it showed significantly greater improvement in CD4 count increase, and in viral load reduction, than AZT plus ddI plus placebo, lasting at least for the 48 weeks the trial was run.

In a separate one-year trial with previously untreated patients, those on the triple combination of nevirapine plus AZT plus ddI had an average CD4 increase of 138 at the end of the trial (computing the average increase from weeks 40-52), and the CD4 count was still increasing after one year. Without the nevirapine, those on AZT plus ddI had an increase of 81 in the same time period (weeks 40-52), and their counts were decreasing. The difference between the 138 increase and the 81 increase was statistically significant. Also, about two thirds of those receiving nevirapine plus AZT plus ddI had their viral load reduced to undetectable levels.

An in-depth article on nevirapine, by Jules Levin of the National AIDS Treatment Advocacy Project, looks in more detail at the nevirapine clinical trial results -- and at safety, drug interactions, viral resistance, status of approvals internationally, and contact information for the expanded access program. This article is available on the World Wide Web at http://www.aidsnyc.org/natap; if you do not have Internet access, you can reach Mr. Levin by fax at 718- 624-8399, or by phone at 718-624-8541.

Free Viral Load Tests: 
Remember to Dial 1 Before 888

Some calls never reached the Roche hotline, but came to private homes and businesses instead. This happened because people did not dial the '1' to indicate a long-distance call; as a result, the first seven digits of the number were taken as a local call, and the last three digits were ignored.

The '888' area code represents a new toll-free phone number, presumably instituted because the familiar '800' numbers are running out. AIDS Treatment News normally does not publish the '1' in front of a long-distance number, since people know to dial it. The current confusion occurred because '888' toll-free numbers are new. We will include the '1' with '888' numbers we publish in the future.

Needlestick Exposure: 
CDC Recommends Three-Drug Regimen

Because the risk of transmission is low -- only about 3 HIV infections per one thousand percutaneous exposures to HIV- infected blood, and because the antiviral drugs can have side effects, treatment is not recommended in very low risk situations (such as exposure to urine or saliva from HIV- positive persons). When treatment is recommended, it should be started very rapidly, preferably within one to two hours of exposure. The treatment suggested is indinavir (Crixivan(R)) plus AZT plus 3TC for four weeks; however, this regimen should be changed in certain cases, such as with a patient likely to be intolerant to one of those drugs or who is taking incompatible medications.

The previous recommendation for occupational exposure to HIV called for treatment with AZT. A case-control study found that this use of AZT alone was associated with a 79% reduced risk of seroconversion. There is no human data on the effectiveness of combination treatment in preventing infection due to occupational exposure to HIV (since it takes a long time to get such data, because cases of seroconversion are rare). But all that is known suggests that combination treatment will probably be more effective than AZT alone.

The complete guidelines were published in the June 7 MMWR (MORTALITY AND MORBIDITY WEEKLY REPORT, of the CDC). According to this publication, updated information about prevention of infection due to occupational exposure to HIV will be available in early 1997 from the CDC's Internet home page (http://www.cdc.gov), and also by fax and telephone.

AIDS and Alternative Medicine: 
A Journalist's Perspective

I started AIDS Treatment News 10 years ago, and the newsletter has now published 245 twice-monthly issues. When we started, we thought that AIDS Treatment News would focus mainly on alternative/complementary treatments -- thinking that physicians and patients were already flooded with mainstream treatment information from journals and from industry marketing departments.

It did not turn out as expected. While some of our most important articles have been about alternative treatments -- for example, the September 1, 1995 interview with acupuncturist John Sinclair of the Immune Enhancement Project in San Francisco -- we have published many more articles about mainstream experimental treatments, or mainstream approved treatments, than about alternative approaches. Partly this is because the journals and pharmaceutical companies have done poorly in getting physicians the mainstream information they need, so most of our readers' questions concern mainstream treatments.

But also, there is much less research on alternative treatments, due to well-known funding difficulties. Research money, from government as well as from industry, is funneled preferentially into development of the most expensive treatment options -- a major though unrecognized upward pressure on the overall cost of medical care. Our reporting has been affected, because most of the new research findings have come from mainstream research. And we have felt compelled to focus on what is new, because no one has had the answer. Existing treatments, both mainstream or alternative, can be helpful, but most of the answers required to save lives will have to come from new research and development.

What has been lost from failing to research alternative treatments?

The big Vancouver international AIDS conference will happen in two months. After one of the earlier meetings, a physician from the developing world, who had just wandered through the high-tech exhibits and research reports, commented, "There is nothing for us here."

That is not surprising, since every medical tradition on Earth except for one has been excluded from any real role in developing new treatments. Only the corporate, high-tech, big-money, FDA-approved research process has been taken seriously. And this year at Vancouver there will be another issue: the unaffordability of the fruits of the big-money tradition, now that it is producing results arguably worth fighting for. Being excluded from AZT monotherapy seldom became a major concern.

But the loss is not only to the developing world, or to the excluded communities within the United States. For if there are important leads to new approaches within indigenous healing traditions -- and certainly there are -- we are unlikely to hear about them. Excluding almost everybody from the search for better treatments will slow that search greatly.

Major Problems in Drug Development

Some of the biggest problems in medical research and drug development affect mainstream and alternative alike. To simplify the recent history of drug development and approval, several years ago there were two major bottlenecks. One of them was obvious and painfully pressing, and has now largely been fixed, at least for AIDS. The other problem was more subtle, and it remains one of the major challenges for today.

When AIDS Treatment News started reporting 10 years ago, the obvious bottleneck was in the late stage of drug development -- the later steps leading up to FDA approval. It was clear that clinical-endpoint trials were going to be required -- and that if a drug did work, it would take years for all but a few people to get it. The drug had to already look good enough that hard-nosed companies would invest many tens of millions of dollars in its development. And people could read about the drug in the newspapers, but could not get hold of it. This bottleneck, of course, affected only mainstream treatments, since anything which gets that close to approval would be considered mainstream by definition.

In most cases we do not have this problem in AIDS today. The current FDA leadership has developed regulations for accelerated approval, which allows a drug to be approved based on easily measured markers like CD4 and viral load -- and encouraged various forms of expanded access, which allow companies to provide a drug to many people before approval. The FDA now goes out of its way to find official, legal ways to make available AIDS drugs that the medical community as a whole has good reason to want to get. There are still problems, however: for example, expanded access can work commercially for some large companies, but others are uninterested, and for small companies it may be out of the question.

But the other bottleneck, early in the drug development process, has not been solved -- and it affects mainstream and alternative treatments as well. This bottleneck, which I believe is the fundamental problem in drug development today, is the difficulty of going from early work to the first credible human data on possible activity or efficacy.

In the case of mainstream treatments, the early work is usually in the laboratory. Treatment leads which show promise commonly do get published in mainstream, peer-reviewed journals. They get published because publication is the lifeblood of academic careers, so the researchers will fight to reach this stage. But then, in almost all cases, development stops cold, no matter how promising the laboratory results may be. With no human data, no one will invest millions of dollars which current rules usually require to be spent before that human data is available.

For alternative treatments, the bottleneck occurs after the treatment is already in human use, sometimes widespread human use, but there are no generally accepted scientific studies or data to support its benefit. Usually those studies never happen -- despite the obvious public health importance of researching treatments which are in widespread use, whether they work or not.

Part of the tragedy is that if a new drug or other treatment approach or idea could reach the stage of early data -- the first credible showing of activity in humans, even if less than a controlled trial -- then the existing system of drug development might respond passably well. Pharmaceutical companies, physicians, academics, and others will start being interested, and the treatment will have the momentum to carry it into further stages of research. But before it has that first credible human data, there is no sufficient evidence, no momentum, to start the ball rolling. Laboratory results, biological plausibility, or popular interest and use, have usually not been enough.

Much of the advance of medicine comes from lucky accidental discovery, in which the unexpected is allowed to reveal itself. Today's system poisons this well of potential discovery, by making research so cumbersome and expensive that it can only test ideas which already have widespread support in advance.

What Can Be Done?

How might research be organized to overcome this particular gap between widespread use of an alternative treatment, and widely credible data showing possible activity or effectiveness? We see several possible approaches. They are relevant not only to researchers, but also to physicians, patients, advocates, public officials, and potential donors who might support research.

• Use of viral load. Viral load testing, now widely used although not quite yet officially approved by the FDA, has made it far easier than before to tell whether or not a drug is working as an antiviral. A major antiviral effect would ordinarily show up in a few days, or a couple weeks at most. This means that the first human trials can now be far shorter than before. The treatments that don't work could be stopped within a couple weeks -- freeing resources to continue the trials for the minority of treatments which did reduce viral load, to get long-term data for them.
• Developing less cumbersome and expensive ways than controlled clinical trials to get credible initial data. The U.S. National Cancer Institute has published guidelines for "best case series" reports from physicians who use unconventional cancer therapies. And in surgery (where randomized controlled trials of operations are now being seriously considered) -- there is also interest in improving case series reports (see THE LANCET, April 13, 1996). The purpose of using case series is not to replace clinical trials, but to help make a preliminary judgment as to what treatments should go into the trials, which will be conducted at great financial and human cost.
• Investigating existing obstacles to credibility. For ten years AIDS Treatment News has been answering phone calls for information about particular treatments. Often the calls come in groups; we will suddenly get a number of calls about some particular treatment, mainstream or alternative. We have had a chance to look at what is behind the calls.

For mainstream treatments, and sometimes for nutritional approaches as well, a flurry of calls usually means that research just published in a high-status journal was reported by major newspapers or TV networks. What is driving this interest is scientific discovery.

But behind a flurry of calls about an alternative treatment, in most cases, is not a scientific advance, but a marketing campaign to make money for someone. A new incarnation of some old pill or machine is being pushed.

Recently we used the Internet's World Wide Web to do computer searches on alternative treatments. We used a search engine called Alta Vista (described below), which immediately checks over 20 million existing Web pages for whatever words we specify, and returns results immediately. About 4,000 pages include the phrase "alternative medicine." But a great many of them were listings of health-food type products for sale. When we asked the search engine to eliminate all those that contained the word "product" or "products," we got the total down to a more manageable 2,000.

The fact that a product is commercially promoted does not mean it doesn't work. But it can make it hard for us to get a sense of whether it works or not. We do not know the people behind the campaign; do they believe in their own product? Do they have evidence, and are they evaluating it well? Or are they only pursuing a marketing challenge, in which their goal is to sell as much as they can, without any need to know whether or not it works?

Occasionally a flurry of phone calls or letters results not from a commercial promotion, but from activities of a true believer. Here the credibility problem is largely the same. It is hard to tell what you can trust and what you cannot.

The pharmaceutical-industry mainstream deals with this problem by having third parties, usually academic or clinical research physicians, conduct its research. While the company pays the money, the researcher's career depends only slightly if at all on whether there are positive results -- but depends centrally on a continued reputation for objectivity.

Perhaps the alternative-treatment world could borrow this system, too. The difference would be that we will never have the money that pharmaceutical companies have, and therefore must find research strategies which are far less expensive. This is possible, since most alternative treatments are already in frequent human use, so trials are much safer than those testing a new chemical entity which no human has ever encountered before.

But the history so far is not always promising. Often academics are misused in a way which constitutes a sale of their name for use in a marketing campaign. Hungry researchers or institutions which have a public reputation are hired to do some laboratory test or other piece of the research on an alternative product -- a test which has little or nothing to do with whether the product works as claimed. The academics do their job competently, but meanwhile their name is plastered on ads or promotional articles, to make the product appear to have credibility it would not otherwise have had. This practice complicates the search for methods to do the research right.

• Better standardization and handling of patient data. Much could be learned without the human and material costs of trials by analysis of data already generated in medical practice. But the data needs to be computerized, in ways which avoid unnecessary inconsistencies between the records of different practices. Then the data might be pooled anonymously -- or if that was not sufficient to protect confidentiality, researchers could get statistical summaries from the different offices and analyze those.
• More openness to and more equal communication with indigenous and traditional healers and traditions. Usually we will have to start our learning process on their terms -- not start with trying to force what they are doing into our preconceived scientific mindset.

Ultimately, to make knowledge widely transportable and useful, we will need to find credible ways of testing proposed approaches. But these ways need to be developed in collaboration. It will often not work to bring in a preconceived piece of scientific methodology developed in other contexts and for other purposes.

One potential resource for starting this learning process is ExtraMED, a new database created by the World Health Organization, of over 200 medical journals in developing countries. These journals are excluded from Medline, Embase, and other major bibliographic databases, and therefore largely unknown to researchers in the developed world. (For more information about ExtraMED, see below).

• Case studies of successful medical advancement. We can learn from history and analysis of important medical advances -- in the Western scientific tradition, but in other traditions as well.
• Building educated donor networks. We must be ready to explain research issues to persons who could contribute major support for research, but who may want to be sure that their money does not go down the same ratholes where so much has gone already. We need to learn what it is about a research project which disposes it to success, and what disposes it to failure -- and be ready to share this knowledge with others.

Appendix: ExtraMED Database

ExtraMED is a database of over 220 biomedical journals selected by the World Health Organization as among the best in the developing world. But almost all of these journals are not indexed in Medline, Science Citation Index, or any other Western indexing service. Therefore most researchers never find out about this published research.

An eye-opening article in the August 1995 SCIENTIFIC AMERICAN, "Lost Science in the Third World" by staff writer W. Wayt Gibbs, compiles appalling statistics on the exclusion of developing-country research from the world's scientific literature. A handful of indexing services have come to serve as gatekeepers of whose work can reach the scientific community. They have allowed only two percent participation in science from 80 percent of the world. And the numbers have become seriously worse during the last ten years.

ExtraMED, now in its second year, claims particular strength "in such topics as AIDS, tropical medicine, communicable diseases, emergency conditions, and traditional medicine." The database is distributed on CD-ROM, which stores the complete text of all pages of all articles as high-quality images -- together with a cumulative index which allows all disks to be searched with one command.

ExtraMED costs $1800 a year for 10 disks (50% less in the developing world). For more information, contact DV Trimmer, Informania Ltd., P.O. Box 1359, London W3 0ZU, England; fax 011-44-1730-265398, email 100060.172@compuserve.com.