Last word: Brain West
Brian West explores the marvel medicines and firm favourites of prevention and treatment through 2007.
It’s been the strangest of years for HIV, for the people living with it, and for the people potentially affected by it. Readers of Positive Nation started off the year with no indication that this magazine was in trouble; that the organisation that ran it was on the verge of bankruptcy; that Positive Nation would then disappear - only to rise again phoenix like from the ashes.
That sense of being on a roller coaster has affected many other areas of HIV. There was optimism earlier in the year about HIV vaccines as the new Merck vaccine was hailed as the best of the present candidates in the fight to stop the spread of HIV. There was genuine shock when it was withdrawn in September when it was shown to be worse than useless. News in the field of microbicides hasn’t been any better either. Apart from the news about circumcision then, there has been no good news with the new technologies to prevent the spread of HIV. The only thing to remember is the old reliable message, condoms work!
But the news about treatments has rarely been better. Never have there been so many new drugs available. So many new targets have entered the field, like integrase inhibitors and CCR5 antagonists. And in the existing drug classes there are new drugs appearing that have different resistance profiles from the present drugs. The choice has never been greater. For people in the past who have been regarded as “heavily treatment experienced,” we were perhaps unable to reach the treatment goal of undetectable viral load on treatment. Now we can. The treatment goal for everyone with these new drugs should be
“under 50.”
Opportunities however come with their associated problems. The opportunity to screw up has likewise never been greater. We have in the past seen new drugs come along and have introduced them haphazardly. We have ended up adding them into existing regimes and losing the benefits of them within a year. The key here is always to find as many active drugs as we can in any new regime and we haven’t always been very good at that. It’s surely more important now than ever that anyone going onto these new regimes goes through a thorough regime of resistance testing, and that they are seen by a doctor who really knows their stuff.
The other question we need to be prepared for with a very cool head is “which one of the new drugs is the dog?” Anyone remember when D4T/Stavudine was the cool new kid on the block? We soon came down from the top of that ride. Now we wouldn’t touch it with a bargepole. Chances are that one of these new drugs will turn out not to be quite the “gold dust” that we think it is now. Which one will it be? And how will we find out? What signs will be looking for? Do we have systems in place to look out for what could be unexpected side effects of the new wonder drugs? Maybe we can’t know. We didn’t know what lipodystrophy looked like until well after the event. But there is a good reason to keep a very close eye on all the new drugs coming along, so that we can spot any warning signs early.
Another part of this odd year sees us finding out that many of the side effects that we always associated with our anti-HIV drugs, turn out not to be the fault of the drugs themselves, but the deadly little monster HIV. Left untreated HIV can increase our chances of heart disease all on its’ own. So if untreated it causes us long term harm, when do we start treatment? Back onto the roller coaster we go again as the prospect of earlier treatment with Cd4 counts of 350 perhaps becomes the norm.
At the end of this year then we come back to square one with prevention. The one thing that we know works is a condom, so use them. It may be back to the future again with earlier treatment for HIV. Brilliant for some, especially now that the newer drugs are far easier to take, but not much use if we are diagnosing people with HIV too late – which of course we are. So how do we improve upon that? And yes, this is a great time to go on a new treatment when you have the greatest choice of excellent new drugs. But we need to get the message across to people that they need to get the best advice on when and how to use these new drugs. And that treatment adherence is as important now as it was a decade ago. It will be a long time before we have a handful of new drugs to choose from again, so let’s not
screw up! +
