by Tri D. Do, MD, MPH
December 2002
Lighthouse Community Center Newsletter
I am the HIV-negative partner of an HIV-positive partner
who has AIDS. My partner is responding well to a "cocktail" of drugs.
What are the chances of his living a full and typical (for a healthy person)
life expectancy? What are some mitigating factors? What are the
reasonable expectations for a breakthrough regarding AIDS?
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Ever since we ushered in the era of highly active anti-retroviral therapy
(HAART), people living with HIV who can afford and tolerate these medications
have seen remarkable improvements in longevity. The beginning of that
era was early 1996 when protease inhibitors became available. People
who might have long since departed are still with us today. Because
it has been seven years, there’s no reason to believe that
those who are responding well, such as your partner, won’t continue to.
Although I’m no oracle, let me report on some recent advances that give us
hope but also reason to pause.
A new medication called atazanavir may prove to be helpful to those who have
experienced increases in their lipids (cholesterol and/or triglycerides)
due to protease inhibitors. This new protease inhibitor not only has
very potent activity against HIV when used with other classes of medications,
but it appears to have a tolerable side effect profile. Similarly, tenofovir,
a relatively new protease inhibitor, has been shown to have a much smaller
effect on lipids when used with efavirenz and lamivudine (3TC). This
may have great benefits down the road, because as we know, elevations in
cholesterol can increase one’s risk for heart attack and other cardiovascular
diseases.
We’ve heard more good news about the newest entry into the antiretroviral
arena: fusion inhibitors. Although it’s tempting to think that
these medications will somehow slow the progress of nuclear physics, in fact
what they do is prevent HIV from ever getting inside a person’s cells and
causing persisting infection—at least in theory. While other the other
classes of medications we’ve come to know such as NRTIs, NNRTIs, and protease
inhibitors all act on the virus once it’s already inside the cell, fusion
inhibitors such as T-20 nip the HIV in the bud. The latest data shows
that it works really well in people who have not responded to other classes
of medications due to adverse effects, drug resistance, or simply poor responses.
And it works just as well in women as in men and also equally across ethnic
groups. It’s an equal-opportunity fighter, as long as you can shell
out the $15,000 per year it costs for this medication (and goodness knows
the government isn’t doing anything to help the indigent, what with cuts
in ADAP this year). Also, this medication requires injections because
it isn’t absorbed through the stomach at all if taken orally.
For people who have had HIV for a long time and are on their third or fourth
medication regimen change, there’s still hope yet. There have also
been advances in how we monitor for resistant virus. Using a “virtual
phenotyping”, some investigators have found they can predict what drugs a
person will be resistant to—it’s much faster than the old-school method of
resistance testing. Also, for those folks who develop resistance because
they’re not getting enough medication, or for those who are having a lot
of side effects, there may be more hope along the way. In general,
there are a number of medications doctors prescribe where we’ll check blood
levels of the drug to see if there’s too much or too little in the system.
We may have similar tests in the future. Some researchers are even
looking at hair samples as a way of checking for the therapeutic levels of
a drug. How painless can that be? All of the technologies mentioned
in this paragraph are still in the works though, so don’t go looking for
these tools at your corner health care provider’s office just yet.
As with other chronic disease, quality of life is key in treating HIV disease.
Having a high pill burden itself can be quite a drag. Speaking of which,
check out the dragapella group, Kinsey Sicks’ rendition of the Jackson Five’s
“ABC” song. It’s called “AZT” and try singing it like you know you
can:
My doctor said my T cells were getting’
kinda low
She said, “Now boy, we’ve gotta try to make those babies
grow.”
She looked inside her big book of pharmacology,
And wrote not one prescription—she gave me sixty three!
AZT. And then you have ddC.
And don’t forget d4T, 3TC,
Vitamin C for your HIV, girl.
Lots of work is being done to get these regimens down to just once a day
. There are a couple of medications coming down the pipe such as emtricitabine
and triphosphorylated lamivudine, so keep your ears to the ground during
the upcoming year.
On the other hand, we’re seeing more and more serious side effects arise
from long-term therapy. In addition to the changes in body fat composition
and lipids, a condition known as hyperlactatemia is rearing its ugly
head as a long term complication of a few antiretroviral regimens.
Your partner’s physician will keep close tabs on certain lab tests if he’s
on one of those regimens or if he starts to develop symptoms.
While this isn’t a good time for such metaphors, it would be safe to say
that we’re winning many small battles against HIV but the outcome of the
bigger war remains to be seen. Nothing that appears to be a candidate
for a cure is within reach. However, each week it seems I read more
about new things we’re learning about HIV and how to fight it. As long
as your partner is doing his best to take medications and negotiate with
his provider on how best to approach side effects, there’s a good chance
he’ll continue to see good health. Wellness is also extremely important,
including fitness, good diet, and a healthy lifestyle. Keep the big
picture in mind to, and push your elected officials for AIDS funding—in research,
prevention, and treatment, at home and internationally—so we can all
continue (or start) to benefit from the advances of the HAART era.
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