For success with HIV meds, it’s best to think beyond just drug effectiveness alone
Words Robert Fieldhouse
Image Russell Plows
When I chose my combination therapy two years ago, my doctor was very clear
about one thing: “If we get you on a combination you can fit into your
life, you cope with any side effects and take all your pills, you can look
forward to a long and healthy life.” My doctor encouraged me to think
about my daily life: work, diet, existing health problems, and sent me to
the adherence nurse to discuss my options. At first I was overwhelmed by the
number of drugs available. I kept asking the same question: ‘Which is
the best combination?” The answer was, “There’s no one best
combination for everyone. You need to think about what is best for you.”
When potency alone is not enough
Even the most potent drugs that boost your CD4 count and suppress your virus
are as good as useless if you can’t tolerate them, or they need to be
taken so many times a day that everyday life becomes a nightmare. While potency
is an important consideration when choosing antiretroviral therapy, the difference
between success and failure hangs on so much more, like tolerability and convenience.
A lot of the anxiety people experience in the run-up to beginning HIV therapy
focuses on the fact that therapy can be a daily reminder of your HIV status.
It can feel like spontaneity has vanished, that your life from now on is going
to revolve around a routine of pill popping. It doesn’t have to be like
that, and the key is choosing the right drugs. Miguel, 37, a keen clubber,
waited until his doctor made it clear that staying off therapy any longer
would pose a great risk to his health. “I resented the idea that the
treatments would put a stop to what I wanted to do. I kept thinking I was
going to be stuck at home all the time, watching the clock until the next
dose. But in reality I’ve managed it, by taking the tablets at 8am and
8pm. I’m at home in the morning at that time, and
mostly in the evening too, apart from at weekends. Of course, I felt restricted
in the first month, but once I got my confidence with it I can now lead the
kind of life I want. I go clubbing a lot and am lucky not to have to take
my meds with food, so I can take them anywhere. You’ve just got to remember
to always have a bottle of water with you.”
Fine-tuning for food
Discussing your day-to-day activities with your doctor can help you to fine-tune
therapy; some drugs need to be taken with food. This can help make them work
better or can sometimes reduce gastrointestinal side effects such as nausea,
vomiting or diarrhoea. But there is little point in taking a twice-daily drug
that needs to be taken with food if you rarely have breakfast, either because
you are not used to eating in the morning or are too busy to eat before going
to work. In this case you would be better off discussing with your doctor
which medications can be taken with or without food.
Chris, 32, tried a couple of different protease inhibitors before he found
one that suited him. “I was having a lot of diarrhoea, especially first
thing in the morning and it was getting to the point where it was making me
late for work. My doctor suggested I switch to another protease inhibitor
as I’d done very well on those drugs. And it worked; within one month
the diarrhoea had cleared up and I felt much more confident. It really was
a case of trial and error but I got there in the end.”
Once- or twice-daily?
Historically, most drugs were taken twice-daily (some such as unboosted protease
inhibitors needed to be taken three times a day). Most people cope very well
with twice-daily dosing, taking the tablets in the privacy of their own home,
morning and evening and using the pill taking to construct a framework around
which to base other activities such as mealtimes. An increasing number of
drugs can be taken once a day (you should check with your doctor or pharmacist).
At the end of the day, it is a personal choice and currently there is little
evidence to suggest that people who take once-daily medications have better
health outcomes than those on twice-daily meds. And the most obvious worry
is that if you miss a dose of once-daily medication and don’t remember
until the next day, your blood levels of the drug may be very low, perhaps
lower than they would have fallen had one out of two daily doses been missed.
Travelling with HIV
Visiting the US may be more difficult than you are used to if you are on meds
as there are entry restrictions for those with HIV. Having the pills on you
can give the game away and some people choose to send the drugs on before
them. Some other countries have restrictions too, so it’s worth checking
with the embassy before you leave. Travelling through time-zones may require
you to adjust when you take your pills; discuss this with your pharmacist.
Considering other health conditions
This summer an editorial published in the British Medical Journal (BMJ) argued
that we should take both our heart disease risk as well as our personal risk
of HIV disease progression into account when selecting when and what to begin
HIV therapy with. There’s sense in this; nobody wants to survive with
HIV to bring on a heart attack ten or 15 years early. Current HIV treatment
guidelines from the British HIV Association state that therapy should begin
when your CD4 cell count is between 200 and 350. Doctors writing in the BMJ
suggest that it may be prudent to wait for your CD4 count to decline to the
lower end of this range before beginning treatment should your risk of heart
disease in the next 10 years be greater than 20 per cent. This allows you
to put mechanisms in place to reduce your overall risk of heart disease: particularly
stopping smoking, considering taking meds to lower blood fats such as cholesterol
and adopting a healthier diet and exercise regimen.
If you have multiple risk factors for heart disease (male, smoker, overweight,
sedentary lifestyle, family history), you should discuss with your doctor
drug options which are the least likely to disturb your lipid levels.
Finally
It doesn’t matter if you are choosing therapy for the first time or
considering switching; it is important to think about your needs and circumstances
and use these to help you select which drug options are best for you.
You should consider your daily routine and try to tailor your combination
to fit your needs. HIV treatment is for life and your choices should reflect
this.
• If you would like to read the complete BMJ article, here is the reference:
Moerman F et al. Highly active antiretroviral therapy: cardiovascular risk
needs to be assessed before starting treatment. BMJ 330: 1341-1342, 2005.
