Special Review from the 4th Antiretroviral Conference

"THE MINIMAL GOAL should be to suppress HIV replication as much as possible, for as long as possible." -- Joep Lange, MD.

Major Trends & Questions

Treatment of all detectable viral loads (Still much debate over giving/not giving HIV meds for long--term non--progressors)

It is still not known which drug combination may be the best to start with. While AZT/3TC has been the standard, some changes have been observed:

• Increase in the use of D4T/3TC.
• Some experts recommend not starting with 3TC, but using ddI to reduce multiple drug resistance.
• Project Inform states: "All studies in which the majority of patients achieved undetectable viral load had this in common: Two or more 'highly active' antivirals were used together by the patient for the first time." Decisions for which drugs to start on may be "easier" in these three circumstances:
• Pregnancy: Despite the lack of benefit (and possible harm) to the patient, AZT monotherapy is still recommended, although soon to go combo.
• Documented recent seroconver--sion: Two reverse transcriptase inhibitors plus one protease inhibitor are recommended.
• Long--term infection with "high" viral load or "low" CD4 count -- Two reverse transcriptase inhibitors plus one protease inhibitor are recommended.

When to Change Drugs

When the drug regimen fail to make viral load undetectable.

What to Change to When a Regimen Fails

The trend is to change one or both of the Reverse Transcriptase inhibitors and add a protease inhibitor. Merely adding a protease inhibitor to a failed regimen is like monotherapy (taking the protease inhibitor alone).

Protease in New Combinations

• Ritonavir & Saquinavir together show dramatic viral load reduction. Concerns are being raised about liver toxicity.
• More understanding of how protease inhibitors interact with each other.
• Viramune (nevirapine)/protease inhibitor interactions have been clarified. Levels of Invirase and Crixivan are shown to be reduced by 28% and 27%, respectively, when used in combination with Viramune. Ask your doctor about dosage adjustments.
• Quadruple antiviral therapy. "There's nothing magic about the number three." (Anne Collier, MD) "Further reduction in viral load in patients with AIDS occured when a second protease inhibitor was added to triple combination therapy." (D. Berger. et al)

Note: Women Alive profoundly regrets not being able to report first hand from the 4th conference on antiretrovirals and opportunistic infections. No member of Women Alive was granted access to this heavily attended and very important event