NO MORE COCKTAILS
By Michael Day
New Scientist 16 Dec. 2000
Four years of "hit hard, hit early" HIV
treatment may be on the way out in the US, as
evidence mounts of the drugs' serious side
AIDS experts in the US are about to complete a humiliating
U-turn when the Department of Health and Human Services
launches its revised HIV treatment guidelines in January.
The revisions will underline the need to hold back from using
powerful antiviral drugs until the immune systems of HIV
patients show significant signs of decline. It reflects the view,
long held by British doctors, that early use of currently
available drugs may do more harm than good.
Charles Carpenter, associate director
of the Brown University AIDS
programme, told a Royal Society of
Medicine meeting in London last week:
"In retrospect, we now realise the risk
of drug toxicity is greatly enhanced by
taking these drugs early."
For the past four years, leading
American physicians have led the "hit
hard, hit early" campaign which
encouraged patients to take cocktails
of powerful antiviral drugs in the early
stages of the disease in the hope of
preventing damage to the immune
British doctors were often ridiculed at conferences and in the
pages of research journals for suggesting the drugs be used
more cautiously, in case they proved too toxic for patients
who take them for years or decades at a time.
Carpenter is in charge of producing the US version of the
International AIDS Society treatment guidelines. They have
just fallen into line with British HIV Association guidelines which
recommend that patients should not get triple therapy until
their "CD4 count"--the number of T-helper immune cells--falls
to less that 350 per millilitre of blood. The normal level is
around 800 per millilitre.
"This shows that for us all medicine is a very humbling
process,"Carpenter told the audience of US and British AIDS
"It's wonderful to see how after a long period you've moved
closer to us," replied Ian Weller, head of clinical HIV research
at University College London. "The hit hard and early crowd
are now hitting hard but later."
Weller, who is also deputy chairman of the Medical Research
Council's HIV Therapeutics Trials Committee, has long voiced
fears that taking a combination of protease inhibitor and
transcriptase inhibitor drugs early on in HIV disease could do
patients more harm than good.
In January, the other major source of guidance for American
doctors treating people with HIV, the DHHS/National Institutes
for Health, will publish their own revised guidelines. New
Scientist has learned these will also adopt the more cautious
approach favoured by British experts.
Anthony Fauci, head of the NIH's AIDS research division
programme, has publicly stated that doctors have
underestimated how difficult it is to stick to the treatments.
Anti-HIV drugs have been linked to a disfiguring redistribution
of body fat, liver disease and damage to mitochondria, as well
as less specific ailments such as nausea and tiredness. The
drugs also have to be taken in complex combinations every
"It does reduce the quality of life for several years," said
Carpenter. But both doctors noted that the drugs have been
successful in extending the lives of people with AIDS.
Nonetheless, Weller added that the start of treatment might
have to be delayed even further, as new side effects emerge.
He noted that the vast majority of serious AIDS-related
infections occurred in people with CD4 counts less than 200.
The speakers agreed that early treatment might be justified in
people who had only just become infected. In such people,
there was still the possibility of protecting a special class of T
cells that are destroyed very early in infection.