WASHINGTON-HIV specialists say generalists should keep out.
With scores of antiretroviral combinations possible and resistance to protease inhibitors lurking around every corner, AIDS specialists say it’s become too risky to trust treatment to less-experienced physicians. Induce resistance, they say, and patients have no other options.
“Once you go down the road to viral resistance, there is no return,” internist Robert Schooley of the University of Colorado told the Conference on Retroviruses here.
Specialists bolster the argument that HIV is too much for generalists with a study that showed physicians who treat five or fewer HIVpatients have a poorer track record than those who treat more. That study was done before three-drug therapy with protease inhibitors became the vogue.
Too many nonspecialists are starting patients on less-than-suppressive combos, and many don’t appreciate subtleties of drugs and their interactions, said Dr. Joep Lange of Amsterdam’s Academic Medical Center. “Grave mistakes are being made.”
But that doesn’t mean that FPs can’t do just as well as infectious disease specialists in HIV, said Dr. Schooley. They just need to do it on a regular basis with many patients.
This “specialists-only” attitude reflects yet another sea change in HIV care. Just two years ago, federal agencies and professional societies were actively promoting HIV care by all physicians. Too many patients were being dumped on too few specialists, said the Agency for Health Care Policy and Research in a January 1994 clinical guideline. It’s been withdrawn for various reasons.
An opinion by the AMA’s Council on Ethical and Judicial Affairs states that “a physician may not ethically refuse to treat a patient whose condition is within the physician’s current realm of competence solely because the patient is seropositive for HIV.” Patients should not be subject to discrimination, it adds.
Change in the face of AIDS is now measured in months, not years. AIDS hospices are closing in city after city. Hospital beds once dedicated to AIDS care are being eliminated, and AIDS-care budgets cut. At a gay-neighborhood hospital in New York, AIDS admissions are down 10%, while clinic visits are up 21%.
Preliminary data from several cities suggest that the AIDS death rate is down, in some places by 30%. Specialists say they can handle the patient volume, because patients have far fewer acute illnesses.
Total HIV eradication was the mantra heard over and over here. “If we settle for less than complete viral suppression, we will do great harm to the individual patient,” said Dr. Lange. “Our minimal goal should be maximum suppression.”
But many were skeptical that HIV would stage a disappearing act so soon. “I doubt that eradication will be possible with our current list of drugs,” Dr. Schooley said.
Still, there were many tantalizing tales of looming eradication reported here. Dr. David Ho’s team at the Aaron Diamond Center in New York reported no detectable virus in serum, semen, or GI lymph tissue of a handful of patients treated with three-drug combos that included one of the already approved protease inhibitors. Dr. Ho hopes to stop therapy one day in a trial to see whether the virus truly has been eradicated.
Based on the rate of immune rebound and the lifespan of various cells, Dr. Ho says it would take about 2½ years for the virus to be cleared from the body-if it can be. And even when HIV RNA is undetectable in immune compartments, particles of HIV proviral DNA can be found.
Other studies show complete HIV suppression is routinely achievable for two years, a few with undetectable viral RNA for three years.
Yet complete suppression is by no means universally achievable. Between 10% and 30% of patients don’t respond fully to a three-drug protease regimen. And missing even an occasional dose or achieving suboptimal serum drug combos can allow resistance mutations to take off and thrive.
But it is clear that complete suppression prevents resistance from emerging. In patients who abruptly stop a completely suppressive regimen at up to 12 months, said Dr. Douglas Richman of UC San Diego, “the virus that emerges is evolutionarily indistinguishable from that at day zero.” Resistance does not develop in most patients if the virus is suppressed to levels below laboratory detection, now at 20 RNA copies/ml.
Many specialists here decried the practice of some generalists of tacking on a protease inhibitor to drugs a patient may have been taking. One approach now in favor is to start patients on a protease inhibitor and simultaneously switch them to two other antiretrovirals new to them.
Regular monitoring via serum RNA load is also deemed necessary, though the optimal interval hasn’t been set.
Studies here of three-drug combos with the protease inhibitors saquinavir (Invirase, Roche), ritonavir (Norvir, Abbott), and indinavir (Crixivan, Merck) extended the generally favorable news from last summer’s Vancouver AIDS conference. For patients who comply fully with the complicated regimen, serum viral load is reduced to undetectable levels in 50% to 65% of patients for 18 months to two years.
But patient compliance is the bugaboo. Those “not ready” for the strict protease regimen-those with unstable lives or a history of irregular prescription renewals-should get a dual combination of the older nucleoside reverse transcriptase inhibitors, said Dr. Richman. -Joe R. Neel
WASHINGTON-HIV specialists say generalists should keep out.
