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Commentary: Aids Cocktails: Better Later Than Sooner?


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Commentary: AIDS Cocktails: Better Later Than Sooner?

A few years ago, picking the best treatment for people infected with the AIDS virus seemed easy. Drugmakers had developed new medicines so potent that they could lower the amount of HIV in the blood to below detectable levels. Some scientists even hoped that a few years of drug treatment would be able to eradicate the deadly bug completely.

As a result, many doctors responded with an all-out pharmaceutical assault. Indeed, the official 1998 guidelines from a panel affiliated with the Health & Human Services Dept. advised doctors to start patients on powerful cocktails when their critical T-cell counts were still a relatively high 500 cells per cubic millimeter--long before the symptoms of AIDS would be expected to appear. "Many thought they knew the answer: Hit early, hit hard," says Dr. Fred M. Gordin, head of infectious diseases at the Veterans Administration Medical Center in Washington.UNEXPECTED COSTS. Not anymore. Yes, the new drugs have been a tremendous boon to those who can afford them. They've slashed the AIDS death rate in America--even as new infections occur at more than 40,000 each year. But now, in a humbling reminder that man is still far from conquering microbes, the Panel on Clinical Practices for Treatment of HIV Infection is about to announce new guidelines that recommend hitting later rather than sooner.

The reason: It's becoming starkly clear that the potent medicines have serious limitations. They offer no hope of eradicating the virus. And their side effects--which include heart disease and cancer--are far worse than originally thought. "The longer we treat, the more long-term toxicity we see," says Dr. Anthony S. Fauci, director of the National Institute of Allergy & Infectious Diseases and co-chair of the treatment panel. Adds Gordin: "We've gone from an era when most people were dying from the illness to a time when they are getting complications from the therapy that are almost as bad."

The guidelines, to be released in early February at a retrovirus conference, will recommend that doctors wait until patients' T-cell counts fall to 350 cells/mm3 before attacking the virus with drug cocktails. "There was a clear consensus that 500 was too high, and everyone agrees 200 is too low," explains Dr. John G. Bartlett, head of infectious diseases at Johns Hopkins University and panel co-chair. The 350 figure was "picked as halfway between the two extremes," he says.

David Barr, director of the Forum for Collaborative HIV Research, calls the change "dramatic--and very, very important." In the U.S., he notes, the majority of HIV-infected people haven't started taking the drugs yet because their T-cell counts are above 500. The new criteria could mean that these scores of thousands of people will delay treatment. "We're talking about years," says Barr, who credits his own health to staying off AIDS drugs until 1996--seven years after he first tested positive for the virus.

The new guidelines have economic as well as health implications. For drugmakers, delays in starting these expensive drugs would mean hundreds of millions of dollars less in revenues in the short term. For patients, though, the choice is even grimmer than it once was. Do they let the virus run amok for years or commit to a complicated drug regimen that will control their lives and harm their bodies?

There is some good news amid the gloom, however. For one thing, companies are already devising drug cocktails that are easier to take. "The first regimens were impossible for the average human to stick with," says Dr. Merle A. Sande, chairman of medicine at the University of Utah. "What we are all waiting for is one pill, once a day--and I think we will get close to that."

Meanwhile, there's encouraging evidence that the immune system can be bolstered to tackle the virus more effectively. And drugmakers are testing promising drugs that attack the virus in new ways. "For every moment of despair for not having perfect treatments, we also realize how far we've already come," says Dr. Robert T. Schooley, head of infectious diseases at the University of Colorado. The next revision to the treatment guidelines may bring us closer to taming this deadly virus.By John Carey; Carey Covers Science and Medicine from Washington.


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