A Call for More Cautious Antiretroviral Treatment

Keith Henry, M.D., a well-known AIDS physician and the medical director of the HIV Clinic at Regions Hospital in St. Paul, Minnesota, has called for a "cautious, patient-focused" approach to HIV treatment, in an article published February 15 in Annals of Internal Medicine1. His article, and an accompanying editorial2 by Oren J. Cohen, M.D., of the U.S. National Institute of Allergy and Infectious Diseases, offer well-informed, balanced discussions of both the advantages and disadvantages of early, aggressive treatment--and the need to reconsider the hit-hard-hit-early philosophy, now that it is clear that eradication is unlikely with current interventions, and that decades of treatment might be necessary.

For example, Dr. Henry describes the enormous benefit of modern antiretrovirals: "Deaths in our HIV population decreased 85% in a 1-year period" when protease inhibitor based therapy was introduced. But he also notes that hope for eradication, "perhaps more than any other assumption...powered enthusiasm for immediately beginning treatment." With eradication not currently possible, he urges a new evaluation of risks and benefits of aggressive vs. conservative antiretroviral treatment.

"Early, aggressive therapy often prematurely exposes patients to risks for medication-related side effects and resistance. A more cautious, patient-focused, long-term approach to therapy would help foster studies of alternative strategies, such as delayed initiation of therapy, protease-sparing therapy, class-sparing therapy, planned drug interruptions, switches in therapy, and immune-based therapy. It is time for clinicians to rethink their approach to the treatment of HIV infection."

Dr. Henry also discusses the financial incentives that direct research toward short-term studies of particular drugs in treatment-naive patients, for example, when most patients are treatment-experienced, and long-term treatment strategy studies are needed. "It is frustrating that an increasing number of clinical studies focus more on what is good for the drug than on what is good for the patient. Little attention is paid to reasonable salvage regimens or use of regimens that involve drugs from different companies."

And Dr. Henry calls for more support for the clinic services which are necessary if patients' medical care, including the difficult drug regimens, is to be properly managed. "The key role of HIV specialists, nurses, case managers and pharmacists is not emphasized enough so that support for the need to supervise the difficult use of these new drugs is often lacking. In today's setting, the most important person involved in the process is the one who answers a question, helps with a medication schedule, or adds insight into care."

The article, with a link to the accompanying editorial, is available online to anyone (you do not need to subscribe to the journal) at: http://www.annals.org/content/vol132/issue4/index.shtml


References

1. Henry K. The case for more cautious, patient-focused antiretroviral therapy. Annals of Internal Medicine. February 15, 2000; volume 132, number 4, pages 306-311.

2. Cohen OJ. Antiretroviral therapy: time to think strategically. Annals of Internal Medicine. February 15, 2000; volume 132, number 4, pages 320-322.