By Maggie Fox

Reuters 18 Jan. '01

Washington -- AIDS experts are backing off from their philosophy to hit the disease as early and as hard as possible, now that they realize they cannot kill the virus outright, a top government health official says.

They will release new treatment guidelines that suggest backing off a bit and not giving patients strong drug cocktails until they really need them.

"We are being a little bit more conservative in our recommendations of when to start,'' Dr. Anthony Fauci, head of the National Institute of Allergies and Infectious Diseases (NIAID), said in a telephone interview.

"Now we are saying you might want to start treating at a little bit lower CD4 count and a little higher viral load.''

When HIV drug cocktails first came out, doctors debated whether patients should start taking them right away or wait until they were really needed. Many studies were done comparing various combinations and start times.

For a while it was hoped that if the virus could be kept dormant for long enough, it would die off in the body. The cocktails, when taken precisely, do suppress the virus.

But in recent years it has become clear that HIV can hide out in the body for decades, even a lifetime, and that it may even continue a low level of replication despite the drugs.

"We know that you are not going to eliminate, you are not going to eradicate the virus,'' Fauci said. "What we can do is control it very well.''

And it has also become clear that the drugs, while keeping patients alive and well, can have serious side-effects. These range from nausea and diarrhea to long-term metabolic changes that may put patients at risk of heart disease, diabetes and bone loss.

"We have been observing, as others have for the past couple of years, that there is a cumulative toxicity with some of these drugs,'' Fauci said.

"We need to allow a degree of flexibility because we don't know what the long-term toxicity will be.''

The AIDS cocktails and a patient's response to them have to be monitored very carefully. Terms such as "CD4 count'' and "viral load'' refer to how much virus there is circulating in the blood and how badly it has damaged the immune system.

Fauci said the new guidelines, to be released in detail next month at an annual scientific meeting of HIV experts in Chicago, will mean tolerating a bit more virus in the body in return for sparing the patient the side-effects and inconvenience of the drug regimens.

But once the drugs are prescribed, they should be taken in full force. "Once you start, then you really should hit hard,'' Fauci, whose institute at the National Institutes of Health helps lead AIDS research, said.

And one very small group of HIV patients is not included in the new guidelines -- those whose disease is caught within days of infection. Studies suggest that if they get treatment right away, their immune systems might remain strong enough, and might be trained, to fight the virus on their own.