Salvage TherapySalvage or rescue therapy in HIV usually refers to someone who is experiencing treatment failure -- a suboptimal response to therapy -- and who no longer has any effective treatment options available. There can be many reasons for treatment failure, including drug resistance, non-adherence, drug side effects, lack of a potent regimen, and pharmacokinetics (what your body does to the drug). But once the treatment fails, your chances for clinical progression, or developing more advanced HIV disease, increase -- especially if your CD4 count is very low. Remember, though, that if this happens, you're not failing your treatment -- your treatment is failing you!
Treatment ExperienceWhen I hear the term treatment-experienced, it always makes me think of a person who has gained great wisdom over the years when it comes to their own HIV treatment -- but we know that this isn't always the case! All it really means is that it's not your first regimen.
In managing treatment-experienced patients, the Department of Health and Human Services (DHHS) Treatment Guidelines recommend evaluating antiretroviral treatment failure, including assessing the severity of HIV disease, treatment history, and results of drug resistance testing while determining the level of prior treatment exposure and resistance -- limited, intermediate, or extensive. The goal of treatment is to achieve maximal virologic suppression, and when viral suppression is difficult or impossible to achieve with currently available drugs, to preserve the immune system and prevent clinical progression. Above all, it's crucial to obtain expert medical advice.
It's important to bear in mind that most people benefit from antiretroviral therapy (ART), and the majority of those on an ART regimen can keep their viral load undetectable for 3-6 years, or even longer. Some factors which have not been associated with treatment failure include gender, race, pregnancy, and a history of past substance use.
A Little HistorySo what does all of this mean to you? Well, for starters, arm yourself with knowledge! Do your research, study the Guidelines, plot out your treatment history, and then assess, along with your provider, where you fall on the spectrum of HIV treatment. Here's mine as an example:
September 1994: Switched to d4T (stavudine, Zerit) 40 mg twice daily because of CD4 count of 177
May 1995: Switched to 3TC (lamivudine, Epivir) 150 mg + d4T twice daily
September 1996: Switched to 3TC + AZT 300 mg + nevirapine (Viramune) 200 mg twice daily after receiving first viral load test -- viral load was 20,800; CD4 count 324
November 1996: Viral load increased to 40,500; switched to 3TC + AZT + indinavir (Crixivan)
August 1998: Developed kidney stones; switched to 3TC + AZT + nelfinavir (Viracept)
June 2001: Due to viral load of 14,600 and the results of a genotypic resistance test, switched to Kaletra (lopinavir/ritonavir) + efavirenz (Sustiva, Stocrin); have had great success with this regimen -- viral load remains undetectable and CD4 count hovers between 700 and 800
I probably would fall somewhere in the "intermediate" level of treatment-experience and resistance. I'm not considered to be on salvage therapy since my current regimen is working and my immune system relatively intact. However, if I were to develop resistance to the drugs that I'm currently on I could be in big trouble, potentially knocking out one or two powerful classes of drugs at the same time. New drugs coming to market this year makes this trouble unlikely. Then too, the side effects of this regimen, increased cholesterol and triglycerides, may soon be catching up with me. Luckily there might be other options that will be just as effective, and with fewer lipid effects.
The New Treatment Paradigm?Today there are many new therapies that are or may soon become available, including: newer protease inhibitors and second generation non-nukes for people with multiple resistance mutations; and entire new classes of drugs, including two integrase inhibitors, Merck's MK-0518 and Gilead's GS-9137, as well as Pfizer's entry inhibitor maraviroc. How well these new drugs will work, and for how long, especially for those who are in need salvage of therapy, remains to be seen.
Finally I hear this question being asked: Is there no longer a need for salvage therapy? While it is true that the need may not be as pressing as it was 10 or 20 years ago, it still exists. Unfortunately as long as there are those who need new medications in order to construct a viable regimen, and until we learn how to develop therapies that are easier to take, have fewer side effects, are more potent and tolerable, and that we are less likely to develop resistance to -- we'll be in need of rescue.
Take care of yourself, and each other.
Jeff Berry is the editor of Positively Aware.
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